ABSTRACT
BACKGROUND: The known loss of dopaminergic cells in the pars-compacta of the substantia nigra that is the hallmark of Parkinson’s disease (PD). The cellular pathophysiology of the motor dysfunction is beginning to be better understood, thereby providing a stronger scientific rationale for surgical interventions. Yet, to date, there are no treatments that prevent, halt, or cure PD. Surgical strategies, offer symptomatic relief or control of motor complications associated with drug treatment. Both pallidotomy and thalamotomy were extensively used in the treatment of PD in the1950’s and 1960’s. With the introduction of levodopa (L-dopa) in the1960’s and the realization of its striking benefits, surgery was almost abandoned and used only for patients with severe tremor. Surgical therapy is now being used earlier and more often. There are currently three brain regions being considered as targets for functional neurosurgery for PD (other than transplantation) either central nervous system lesions (thalamotomy, pallidotomy, or subthalamic nucleus [STN] lesions) or deep brain stimulation. These targets are: The ventral intermediate nucleus of the thalamus, the internal segment of the Globus Pallidus, and the STN. AIM: The objective of the study was to assess the outcome (3 months and 6 months) of lesioning procedures in PD patients meeting the inclusion criteria. METHODS: A prospective clinical study conducted on ten idiopathic PD (IPD) patients during the period from October 2018 to March 2021 at Cairo University Hospitals. This study was concerned to improve the motor symptoms of IPD patients by stereotactic radiofrequency ablative procedures. Cases were restricted to ten patients due to the COVID-19 pandemic and restriction of elective cases for chronic patients at Cairo University hospitals. RESULTS: In our study, we operated on ten IPD patients who were meeting our selection criteria by ablative procedures contralateral to Parkinsonian symptoms. Age of the patients ranged 17–70 years with mean of 50.5 ± 16.35 y with predominance in males representing six patients. Mean duration of PD according to history ranged from 2 to 12 year with mean of 8 ± 3.1 years. Patients were divided into three groups according to their presentation and the operation done for them. Thalamotomy group: Preoperatively, the Unified PD Rating Scale (UPDRS) III off and on, respectively, was 24.4/15.2 and postoperatively was 13/7.4 with improvement 47%/51%. The tremor subscore was 5.4/2.8 preoperatively and 1.4/0.8 postoperatively with average of 72% improvement. The UPDRS II pre was 17.2/11.6 and post it became 10.6/7 with 39% improvement modified H & Y 2.4/1.7 pre and postoperatively (29% improvement). Pallidotomy group: Preoperatively, the UPDRS III off and on, respectively, was 38.5/23.5 and postoperatively was 28/16 with improvement 27%/32%. The rigidity subscore was 5/2.5 preoperatively and 2/1 postoperatively with average of 60% improvement. The bradykinesia subscore was 9/5.5 preoperatively and 5.5/2.5 postoperatively with average of 47% improvement. The dyskinesia subscore was 4.5 preoperatively and 1.2 postoperatively with average of 71% improvement. The UPDRS II pre was 22/12.5 and post it became 16/10 with 25% improvement modified H & Y 2.75/2.25 pre & postoperatively (18% improvement). Combined group: Preoperatively, the UPDRS III off & on respectively was 41.33/28.67 and postoperatively was 15.67/11.33 with improvement 62%/60%. The rigidity subscore was 5/3.33 preoperatively and 1.67/1 postoperatively with average of 68% improvement. The bradykinesia subscore was 10/6 preoperatively and 4/1.33 postoperatively with average of 72% improvement. The UPDRS II pre was 28.33/19.33 and post it became 16.33/10.67 with 43% improvement modified H and Y 2.83/2 pre and post-operatively (29% improvement). Postoperatively, there was a high significant statistical finding in all clinical score and subscore of Parkinsonian symptoms. CONCLUSION: The study concludes that lesioning procedure should be revisited globally using the modern tech iques of targeting and controlled thermal lesion protocols guided by capsular somatotopy and intraoperative macroelectrode stimulation, that will improve the outcome dramatically. Ablative procedures proved their efficacy in controlling motor symptoms of IPD and their cost-benefit in low and middle-income nations.
ABSTRACT
Diabetes mellitus (DM) is one of the major risk factors for COVID-19 complications as it is one of the chronic immune-compromising conditions especially if patients have uncontrolled diabetes, poor HbA1c and/or irregular blood glucose levels. Diabetic patients' mortality rates with COVID-19 are higher than those of cardiovascular or cancer patients. Recently, Bacillus Calmette-Guérin (BCG) vaccine has shown successful results in reversing diabetes in both rats and clinical trials based on different mechanisms from aerobic glycolysis to beta cells regeneration. BCG is a multi-face vaccine that has been used extensively in protection from tuberculosis (TB) and leprosy and has been repositioned for treatment of bladder cancer, diabetes and multiple sclerosis. Recently, COVID-19 epidemiological studies confirmed that universal BCG vaccination reduced morbidity and mortality in certain geographical areas. Countries without universal policies of BCG vaccination (Italy, Nederland, USA) have been more severely affected compared to countries with universal and long-standing BCG policies that have shown low numbers of reported COVID-19 cases. Some countries have started clinical trials that included a single dose BCG vaccine as prophylaxis from COVID-19 or an attempt to minimize its side effects. This proposed research aims to use BCG vaccine as a double-edged weapon countering both COVID-19 and diabetes, not only as protection but also as therapeutic vaccination. The work includes a case study of regenerated pancreatic beta cells based on improved C-peptide and PCPRI laboratory findings after BCG vaccination for a 9 year old patient. The patient was re-vaccinated based on a negative tuberculin test and no scar at the site of injection of the 1st BCG vaccination at birth. The authors suggest and invite the scientific community to take into consideration the concept of direct BCG re-vaccination (after 4 weeks) because of the reported gene expressions and exaggerated innate immunity consequently. As the diabetic MODY-5 patient (mutation of HNF1B, Val2Leu) was on low dose Riomet® while eliminating insulin gradually, a simple analytical method for metformin assay was recommended to ensure its concentration before use as it is not approved yet by the Egyptian QC labs.