Clinical criteria and diagnostic assessment of fibromyalgia: position statement of the Italian Society of Neurology-Neuropathic Pain Study Group.

BACKGROUND: The role of central and/or peripheral nervous system dysfunction is basically fundamental in fibromyalgia. AIM: The aim of this position statement on behalf of the Neuropathic Pain Study Group of the Italian Society of Neurology is to give practical guidelines for the clinical and instrumental assessment of fibromyalgia (FM) in the neurological clinical practice, taking into consideration recent studies. METHODS: Criteria for study selection and consideration were original studies, case-controls design, use of standardized methodologies for clinical practice, and FM diagnosis with ACR criteria (2010, 2011, 2016). RESULTS: ACR criteria were revised. For diagnostic procedure of small-fiber pathology, 47 studies were totally considered. Recent diagnostic criteria should be applied (ACR, 2016). A rheumatologic visit seems mandatory. The involvement of small fibers should request at least 2 among HRV + SSR and/or laser-evoked responses and/or skin biopsy and/or corneal confocal microscopy, eventually followed by monitoring of metabolic and/or immunological/ and or/paraneoplastic basis, to be repeated at 1-year follow-up. CONCLUSIONS: The correct diagnostic approach to FM could promote the exclusion of the known causes of small-fiber impairment. The research toward common genetic factors would be useful to promote a more specific therapeutic approach.

The effects of containment measures in the Italian outbreak of COVID-19.

The COVID-19 pandemic is spreading worldwide. Italy emerged early on as the country with the largest outbreak outside Asia. The outbreak in Northern Italy demonstrates that it is fundamental to contain the virus' spread at a very early stage of diffusion. At later stages, no containment measure, even if strict, can prevent the saturation of the hospitals and of the intensive care units in any country. Here we show that it is possible to predict when the intensive care units will saturate, within a few days from the beginning of the exponential growth of COVID-19 intensive care patients. Using early counts of intensive care patients, we predict the saturation for Lombardy, Italy. We also assess short-term and long-term lockdown effects on intensive care units and number of deaths. Governments should use the Italian outbreak as a precedent and implement appropriate containment measures to prevent the saturation of their intensive care units and protect their population, also, and above all, in anticipation of a possible second exponential spread of infections.

The choice of endogenous controls in exosomal microRNA assessments from biofluids.

The assessment of differentially expressed microRNAs in patients and healthy controls is important to identify potential tumor biomarkers. Recently, it has been shown that the microRNA levels in exosomes are more correlated with the clinical-pathological variables than vesicle-free microRNAs (miRNAs) in biofluids; therefore, there is an increasing interest in these specific evaluations. However, these measurements can be affected by experimental problems that not always are evaluated and/or by inadequate procedural choices. In particular, exosome isolation and miRNA extraction procedures are crucial to avoid contaminations, and even the choice of the most suitable purity controls is important. Moreover, a stable endogenous RNA should be used for normalization of miRNA expression obtained by reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) in order to make these measures comparable among different samples. A rushed choice of the endogenous control can bias study conclusions without revealing inconsistencies. Unfortunately, a few studies systematically identified the best normalizer for their specific experimental context. Instead, sometimes, the normalization procedures were performed in a disputable way or the normalizer choices simply based on the previous literature. Here, we reviewed the studies where the exosomal miRNA profiling was assessed in human biofluids to point out the adopted procedures and the specific endogenous controls chosen for normalization.

Identification of candidate miRNA biomarkers for pancreatic ductal adenocarcinoma by weighted gene co-expression network analysis.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy with a dismal prognosis which is, among others, due to a lack of suitable biomarkers and therapeutic targets. Previously, basic gene expression analysis methods have been used for their identification, but recently new algorithms have been developed allowing more comprehensive data analyses. Among them, weighted gene co-expression network analysis (WGCNA) has already been applied to several cancer types with promising results. METHODS: We applied WGCNA to miRNA expression data from PDAC patients. Specifically, we processed microarray-based expression data of 2555 miRNAs in serum from 100 PDAC patients and 150 healthy subjects. We identified network modules of co-expressed miRNAs in the healthy subject dataset and verified their preservation in the PDAC dataset. In the non-preserved modules, we selected key miRNAs and carried out functional enrichment analyses of their experimentally known target genes. Finally, we tested their prognostic significance using overall survival analyses. RESULTS: Through WGCNA we identified several miRNAs that discriminate healthy subjects from PDAC patients and that, therefore, may play critical roles in PDAC development. At a functional level, we found that they regulate p53, FoxO and ErbB associated cellular signalling pathways, as well as cell cycle progression and various genes known to be involved in PDAC development. Some miRNAs were also found to serve as novel prognostic biomarkers, whereas others have previously already been proposed as such, thereby validating the WGCNA approach. In addition, we found that these novel data may explain at least some of our previous PDAC gene expression analysis results. CONCLUSIONS: We identified several miRNAs critical for PDAC development using WGCNA. These miRNAs may serve as biomarkers for PDAC diagnosis/prognosis and patient stratification, and as putative novel therapeutic targets.

Phosphorylated mTOR is associated to androgen receptor expression in early triple-negative breast cancer.

The significance of phosphorylated mTOR (p-mTOR) expression is unknown in triple-negative breast carcinoma (TNBC). The aims of the present study were to assess the expression of p-mTOR in early TNBC and to evaluate possible correlations between androgen receptor (AR) expression, clinicopathological parameters and disease outcome. Between January 2009 and December 2013, all consecutive patients who were diagnosed and completed the treatment of invasive TNBC at our institution were eligible for this analysis. Patients with stage IV disease were excluded. The evaluation of p-mTOR immunohistochemical staining was semi-quantitatively considering both the percentage of positive tumor cells (range, 0-100%) and staining intensity (range, 0-3+). Ninety-eight TNBC patients were included. Approximately 33% of cases were p-mTOR positive and there was no association between positive immunostaining for p-mTOR and DFS (p=0.74) and OS (p=0.81). p-mTOR positivity was associated with small tumor size (p=0.03) and AR expression (p=0.04). High expression of p-mTOR may drive tumor proliferation in almost one third of TNBC. The biological association between mTOR activation and AR pathway suggests that there may exist a subgroup of TNBC in which the combination of both AR antagonism and mTOR inhibition should have a synergistic effect on cell growth and tumor progression.

Coexistence of GABAA and GABAB receptors on A delta and C primary afferents.

Intracellular recordings from adult rat dorsal root ganglion neurones were performed in vitro and the coexistence of two gamma-aminobutyric acid (GABA) receptors on the membrane of identified A delta and C primary afferents was demonstrated. Transient applications of GABA (10(-6)-10(-2) M) evoked dose-dependent depolarizations and increased membrane conductance. The responses were mimicked by muscimol, isoguvacine, THIP and 3 amino propane sulphonic acid (3 APS); they were blocked by bicuculline and picrotoxin. Pentobarbitone induced an increase of GABA-induced depolarizations. Perfusion of tetraethylammonium (TEA, 7.5 mM) and intracellular injection of Cs+ ions unmasked the Ca2+ component of action potentials, which appeared as long-lasting plateau depolarizations. Such action potentials were shortened in the presence of methoxyverapamil (D600, 5 X 10(-6)-10(-5) M) and in a medium without Ca+ ions. Prolonged (5-10 min) perfusion of GABA (10(-9)-10(-5) M) shortened the Ca2+ component of action potentials. This effect was mimicked by baclofen (10(-7)-5 X 10(-6) M) and muscimol (5 X 10(-7)-10(-5) M) and was not affected by bicuculline perfusion (5 X 10(-6)-10(-5) M). Isoguvacine (2.5 X 10(-5) M) did not affect action potential duration. It is concluded that two GABA receptors coexist on the membrane of slow conducting primary afferents: the bicuculline-sensitive GABAA receptor mediates depolarizations and the bicuculline-insensitive GABAB receptor shortens the calcium component of action potentials.

[Applications and results of photon absorptiometry]. / Applicazioni e risultati della mineralometria a raggi fotonici.

Bone mineral content (CMO, mg/cm2) was measured at the distal radius by dual photon absorptiometry (DPA, I125, Am241) in 1.161 women (w), aged 20-87 years. Women were subdivided into different groups according to the presence and duration of menopause. For gross evaluation of spinal osteoporosis (OP), the results of spinal X-rays were graded as follows: score 0: no signs of OP; score 1: aspecific signs of OP; score 2: typical signs of OP; score 3: wedging or collapse of one or more vertebrae. Women in postmenopausal state showed significantly reduced CMO (p less than .0005) when compared to women in premenopausal state; a significant correlation was found between CMO and years since menopause (p less than .0001). Concerning the relationship between CMO and spinal score, a progressive decreases in CMO from score 0 to score 3 was present and the correlation was significant (p less than .0001). In addition, women with score 3 showed a mean CMO below the "fracture threshold", in spite of the large overlap in individual CMO values. Our data suggest that radial DPA should be maintained as a "screening" procedure for OP.

Prevention of glucocorticoid-induced osteopenia: effect of oral 25-hydroxyvitamin D and calcium.

Twenty-four patients (9 M and 15 F, age range 51-82) with polymyalgia rheumatica receiving 6-methylprednisolone for a period of 9 months (16 mg/daily/two weeks, 14 mg/daily/two weeks, 12 mg/daily/1 month, 10 mg/daily/1 month, 8 mg/daily/1 month, 6 mg/daily/1 month and 4 mg/daily for the last four months) were randomly assigned to receive either 250HD3 (35 mcg/day for 25 days/month) (Group A) or placebo (Group B) in a double-blind study. All patients also received 500 mg elemental calcium daily. Before and at 3, 6 and 9 months ESR, tenderness on palpation and subjective pain were evaluated. At the same times, mineral metabolism parameters (serum calcium, phosphorus, alkaline phosphatase, 24-h urinary calcium, phosphate and 24-h hydroxyproline excretion) and radial bone mineral content (BMC) were evaluated. Activity indexes (ESR and clinical parameters) improved in both groups. Furthermore, serum alkaline phosphatase and 24-h hydroxyproline excretion decreased significantly only in Group A, and BMC decreased significantly in Group B but rose slightly in Group A. No side effects were observed in any of the patients.

[Acute progressive respiratory insufficiency caused by diffuse interstitial pulmonary disease in a diabetic patient with dilated myocardiopathy]. / Insufficienza respiratoria acuta progressiva da interstiziopatia polmonare diffusa insorta in diabetica con miocardiopatia dilatativa.

This report describes the case of a 70-year-old female suffering from diabetes mellitus and dilatative cardiomyopathy with congestive heart failure. It is likely that alveolar-capillary membrane damage occurred apart from cardiac involvement. Diffuse interstitial pulmonary fibrosis subsequently occurred with consequent acute progressive respiratory failure and death. The cause of the damage to the alveolar-capillary membranes is still unknown and we thought that long-term administration of captopril might have contributed to the damage itself, since like all ACE-inhibitors, captopril is able to bring about tissular storage of both bradykinin and prostaglandins and therefore alter the pulmonary reactivity to phlogistic stimuli.

Development of a standardized model for liver failure in pigs: anatomopathophysiologic findings after extended liver resection.

Eighteen pigs weighing a mean 19 ± 4 kg, were divided into group 1 (n = 2), that underwent resection of the left lateral lobe, group 2 (n = 2), resection of the left median and right median lobes; and group 3 (n = 18), resection of the left lateral, left median, right median, and right lateral lobes. All animals were followed for 5 days. Liver failure (n = 8) leading to animal death within 3 days after surgery was observed in 65% of group 3, whereas no group 1 or 2 animal experienced liver insufficiency. Multivariate analysis revealed that the extent of liver resection expressed as a percentage of total body weight <2.3%, international normalized ratio > 1.6 as postoperative day 2, serum bilirubin > 4.2 on postoperative day 2, and serum lactates > 9 mmol/L after resection were independent predictors of liver failure (P < .05). The number of resected liver lobes was not a good predictor of liver failure in swine, whereas the extent of resection expressed as a percentage of total body weight was an independent predictor of early liver failure. A resected liver-to-body weight ratio >2.3% was associated with a 65% probability of developing liver insufficiency. This parameter may be useful when developing a model of liver failure after extended liver resection in swine.

New approach to detect seismic surface waves in 1Hz-sampled GPS time series.

Recently, co-seismic seismic source characterization based on GPS measurements has been completed in near- and far-field with remarkable results. However, the accuracy of the ground displacement measurement inferred from GPS phase residuals is still depending of the distribution of satellites in the sky. We test here a method, based on the double difference (DD) computations of Line of Sight (LOS), that allows detecting 3D co-seismic ground shaking. The DD method is a quasi-analytically free of most of intrinsic errors affecting GPS measurements. The seismic waves presented in this study produced DD amplitudes 4 and 7 times stronger than the background noise. The method is benchmarked using the GEONET GPS stations recording the Hokkaido Earthquake (2003 September 25th, Mw = 8.3).

Cesarean section during ECMO support.

This article presents the case of a pregnant woman affected by A/H1N1 flu progressed to ARDS requiring rescue therapy by VV ECMO. Due to the early gestational age, the patient was placed on ECMO before delivery. Four weeks after VV-ECMO placement, a Cesarean section was successfully performed while on ECMO support. One week after delivery, the patient was weaned from ECMO and at 8 weeks from admission she was discharged home without O2 support. The newborn is alive and was discharged at 40 days of age on neurological follow-up.

End-of-life care is still a challenge for Italy.

The aim of this paper was to review current end of life (EOL) practice in Italy. The authors have made an appraisal of the existing literature in order to understand current end of life care practice in Italy. This manuscript focuses on analyzing the dying process, the transoceanic similarities and differences in the end of life decision-making practice, and the family involvement. The authors acknowledge the importance of the recent Englaro court case verdict on current practice in Italy. Dying has changed as a process over the last century in term of causes of death, costs, communication of the prognosis, and needs of the patient's family. Regardless of national and international guidelines, there is no agreement among Italian doctors regarding the gold standards of daily clinical practice at the EOL.

[Comparative analysis of the facilitating effects induced on muscular periphery by the microstimulation of various cerebellar nuclei]. / Analisi comparata degli effetti facilitatori indotti sulla periferia muscolare dalla microstimolazione di nuclei cerebellari diversi.

The facilitatory effects evoked on the motor periphery by the activation of neuronal pools in cerebellar nuclei were analized in 13 cats. The aim of the work was to compare the frequency and the characteristics of the motor facilitations induced on the ipsilateral forelimb by the microstimulation of cerebellar foci in the fastigial (CBM or in the interposital (NIA) nucleus. CBM or NIA sites, previously identified for the motor effects, were microstimulated, together with the contralateral motor cortex, to give evidence of the facilitations. It was observed that 51% of the NIA motor sites, 46% of the rostral and 33% of the caudal CBM ones, were able, when activated, to evoke facilitatory effects on at least one muscle. The most frequent motor pattern observed following NIA microstimulation was the contraction of a proximal muscle and simultaneously the facilitation of a distal one. Similar responses were detected upon activation of neuronal pools in both zones of CBM. A good number of CBM foci (39% in the rostral division and 33% in the caudal one), however, was unable to induce facilitation, eliciting, upon stimulation, only massive axial movements. Distal muscles were involved by facilitatory effects in a higher number of cases following NIA stimulation (61% of all the facilitatory responses) than CBM rostral (39%) or caudal (43%) one. Furthermore, a particular characteristic of a good percentage of CBM facilitating foci (36% in rostral and 28% in caudal CBM) was the capability to elicit motor activity in the contralateral side and simultaneously facilitation in the ipsilateral one.(ABSTRACT TRUNCATED AT 250 WORDS)

Responses of cerebellar fastigial neurons to single muscle activation.

In lightly barbiturized cats, the discharges of neurons in the cerebellar fastigial nucleus (CBM) were recorded while single muscles in ipsilateral forelimb were activated by direct stimulation. The aim was to verify whether CBM cells could selectively detect the activity of afferent fibers from a muscle or a joint and to compare the various response characteristics of the rostral and the caudal division of the nucleus, which are known to control a different muscular periphery. Six muscles were routinely tested, two axial, two proximal and two distal ones. A good percentage of neurons in both partitions of the nucleus responded to the muscles tested (53% and 48% in the rostral and caudal part, respectively). In the rostral part of CBM a large proportion of cells (78% of those responsive) were influenced by one or more muscles having either the same function (the extensors or flexors) or acting on the same joint. Many such neurons showed a marked capability to respond to activation of distal muscles and a prevalence of inhibitory responses mainly on contraction of extensor and axial muscles. In the caudal division of the nucleus, 47% of the responsive cells displayed a stereotyped discharge pattern (excitatory or inhibitory) in response to activation of any tested muscle. In contrast to the rostral CBM the incidence of responses to proximal and distal muscles was about equal in the caudal CBM and a majority of neurons had excitatory responses to flexor muscle contraction. The latencies of the excitatory effects ranged from 8 to 53 ms in rostral and 9 up to 69 ms in caudal CBM.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple and reversible osteolytic lesions: an unusual manifestation of behcet's disease.

We describe a patient with Behcet's disease (BD) who developed multiple and reversible osteolytic lesions during the course of disease. The possible relationships between BD and this very unusual manifestation are discussed.

Deflazacort versus methylprednisolone in polymyalgia rheumatica: clinical equivalence and relative antiinflammatory potency of different treatment regimens.

OBJECTIVE: To assess the clinical efficacy and equivalence of a daily vs alternate day regimen, and the potency ratio between 2 glucocorticoids, deflazacort and 6-methylprednisolone. METHODS: Thirty-one patients with recent onset polymyalgia rheumatica (PMR) were randomly assigned to deflazacort (n = 16) or 6-methylprednisolone (n = 15), according to a 2 period (duration of each period = 6 weeks), crossover, open design for comparing 2 dose regimens (daily vs alternate day), and according to a between-patients, double blind design for comparing the therapeutic effects of the 2 glucocorticoids (deflazacort vs 6-methylprednisolone). The patients, either during alternate day or daily regimen, were treated with fixed oral doses for the first 2 weeks (assuming a potency ratio deflazacort/6-methylprednisolone of 1.5 mg/1.0 mg: deflazacort 24 mg or 6-methylprednisolone 16 mg, daily; deflazacort 48 mg or 6-methylprednisolone 32 mg, alternate day), and with titrated doses for the next 10 weeks. RESULTS: Two patients dropped out during the first 6 week period. The time course and extent of the improvement of disease activity indices (limb-girdle pain, morning stiffness, erythrocyte sedimentation rate, C-reactive protein, and plasma fibrinogen) were not statistically different under the 2 regimens. The satisfactory equivalent glucocorticoid response observed in 12 pairs of patients treated with deflazacort and 6-methylprednisolone progressed significantly from baseline to the end of the study, under daily or alternate day regimen, with no significant difference between the 2 glucocorticoids. Deflazacort proved less potent than 6-methylprednisolone (1.78 mg: 1.0 mg minimum effective daily dose; 1.68: 1.0, alternate day), but equally effective. CONCLUSION: The 2 dose regimens, 6-methylprednisolone and deflazacort showed no significant differences in terms of efficacy during the short term treatment of PMR. Deflazacort proved less potent than initially estimated.

Electrophysiological study of GABAA versus GABAB receptors on excitation-secretion coupling.

Inwardly-directed Ca++-currents are caused by numerous types of action potentials which would not otherwise cause secretion. This process is regulated electrically and by neurotransmitters. We have studied in vitro the ionic mechanisms of GABA-mediated presynaptic inhibition and thereby the distinctive characteristics of GABAA and GABAB receptors: i.e., the GABAA system, which produces such short-lasting changes that there is an instantaneous reduction of spike amplitudes, in particular by opening Cl- -conductance, and the GABAB system, which results directly in inhibition of secretion due to a tonic depression of Ca++-currents. The principal aim was to determine if GABAB/Ca++ receptors could coexist on a membrane already possessing a large number of GABAA/Cl- sites available for presynaptic inhibition. Intracellular recordings of A delta and C dorsal root ganglion cell bodies were used as a model for the study of preterminal axonal membranes. Results were tentatively correlated with those obtained extracellularly by recording Ca++ and K+ movements (Cl- being assessed indirectly) from a set of other cells which also secrete neuropeptides by exocytosis: e.g., endings of unmyelinated fibres in the neurohypophysis and clusters of innervated gland cells in the pars intermedia. In recent years there has been a growing interest in receptors for neurotransmitters (e.g., monoamines, peptides, gamma-aminobutyric acid) modulating Ca++-dependent secretion in various biological systems (14-16, 24, 25, 29, 34). Modulation is possible either by changing the basic characteristics of the ionic currents during a standard action potential (Na+/K+ voltage transients being markedly altered by repolarizing K+ currents) or by any kind of direct action on voltage-dependent Ca++-channels: the latter will allow Ca++ to enter the cell in graded amounts not only as parts of well-defined Ca++-spikes (16, 14, 39; see also 24, 26, 28) but of well-defined Ca++-spikes (16, 14, 39; see also 24, 26, 28) but possibly also along complex sequences of tail-currents (for the biophysics, see 28, 29). Accordingly, it is essential to study presynaptic actions of transmitters in systems where spikes can be recorded, though presynaptic receptor activation can sometimes be identified by other means than spiking patterns (e.g., membrane effects in relation to other well-defined ionophores). The study of cells which are in contact with synapses synthesizing and releasing gamma-aminobutyric acid (GABA) has drawn much of the attention given to these problems.(ABSTRACT TRUNCATED AT 400 WORDS)