MRgFUS thalamotomy for the treatment of tremor: evaluation of learning curve and operator's experience impact on the procedural and clinical outcome.

BACKGROUND: MRgFUS Vim ablation is increasingly used for the treatment of tremor in ET e PD patients but there is little published research on the importance of operator experience in this procedure. This study aims to evaluate the learning curve and the influence of the operator experience on the procedural and clinical outcomes. METHODS: We retrospectively evaluated 90 patients (38 ET, 52 PD) submitted to MRgFUS unilateral thalamotomy in the period between February 2018 and July 2020. Clinical endpoints, procedural times, and technical parameters were recorded in all procedures. Based on the time of treatment, patients were divided into three groups of 30 units each, comparing all variables between each time period group. RESULTS: In Group A, the average patient preparation time was 120.6 min, the treatment time was 105.2 min, the number of was sonications 14.1, and the mean target shifts 3.1. In Group B, the mean preparation time was 105.5 min, the treatment time was 89.5 min, the number of sonications was 13.2, and the target shifts 3.0. Group C showed inferior values of preparation time (101.9 min), treatment time (71.7 min), numbers of sonications (10.6), and shifts (1.7). Thalamotomy-related complications occurred in 9 patients of Group A, 2 of Group B, and 5 of Group C. Tremor relapse occurred in 7 patients of Group A, 3 of Group B, and 2 of Group C. The days of hospitalization were comparable in the three groups. CONCLUSIONS: The operators experience is associated with the improvement of clinical and procedural outcome in MRgFUS thalatomy for the treatment of ET and PD tremor.

Prognostic value of brain tissues' volumes in patients with essential tremor treated with MRgFUS thalamotomy.

MRgFUS Vim thalamotomy is a novel, effective, minimally invasive therapeutic option for patients with essential tremor (ET). Among the selection criteria, some parameters related to the patient's anatomy, such as the skull density ratio (SDR), are well recognized. The role of brain tissue interposed between the target and the ultrasound transducers has never been explored. Therefore, the purpose of our study was to evaluate the correlation and the possible predictive value between brain tissue volumes (grey matter - GM, white matter - WM, and cerebrospinal fluid - CSF) and several treatment-related variables (periprocedural parameters, MRI imaging findings, and the clinical outcome). We analysed data from thirty ET patients previously submitted to MRgFUS thalamotomy. Pre-treatment images were automatically segmented in sopra-tentorial (ST) WM, GM, and CSF using SPM 12. The most significant findings were a positive correlation of the ST-GM with the Accumulated Thermal Dose (ATD) (p < 0,001) and a negative correlation of the ATD temperature with ST-CSF and ST-TIV (p < 0,001). Ultrasound propagation speed is lower in fluids than brain tissues. Also, WM has an attenuation rate of 1.5 higher than the GM. Therefore, the difference in the ATD may be explained by the different acoustic properties of normal brain tissues interposed between the transducers and the VIM.

Multi-center observational study on occurrence and related clinical factors of neurogenic heterotopic ossification in patients with disorders of consciousness.

Aims: to assess occurrence and clinical correlates of neurogenic heterotopic ossifications (NHO) in patients with prolonged disorder of consciousness (DoC).Design: multi-center cross-sectional observational study.Setting: 23 intensive neurorehabilitation units.Subjects: 287 patients with prolonged disorder of consciousness (DoC; 150 in vegetative state, VS, and 128 in minimally conscious state, MCS) of different etiology (vascular = 125, traumatic = 83, anoxic = 56, others = 14).Main Measures: clinical evidence of NHO confirmed by standard radiological and/or sonographic evaluation; Coma Recovery Scale-Revised; Disability Rating Scale (DRS); Early Rehabilitation Barthel Index; presence of ventilator support, spasticity, bone fractures and paroxysmal sympathetic hyperactivity.Results: 31 patients (11.2%) presented NHO. Univariate analyses showed that NHO was associated with VS diagnosis, traumatic etiology, high DRS category and total score, and high occurrence of limb spasticity and bone fractures. A cluster-corrected binary logistic regression model (excluding spasticity available in a subset of patients) showed that only lower DRS total score and presence of bone fractures were independently associated with NHO.Conclusions: NHO are relatively frequent in patients with DoC, and are independently associated with functional disability, bone fractures and spasticity. These findings contribute to identifying patients with DoC prone to develop NHO and requiring special interventions to improve functional recovery.

Multi-center study on overall clinical complexity of patients with prolonged disorders of consciousness of different etiologies.

Aim: to assess overall clinical complexity of patients with acquired disorders of consciousness (DoC) in vegetative state/unresponsive wakefulness syndrome (VS/UWS) vs. minimally conscious state- MCS) and in different etiologies..Design: Multi-center cross-sectional observational study.Setting: 23 intensive neurorehabilitation units.Subjects: 264 patients with DoC in the post-acute phase: VS/UWS = 141, and MCS = 123 due to vascular (n = 125), traumatic (n = 83) or anoxic (n = 56) brain injury.Main Measures: Coma Recovery Scale-Revised, and Disability Rating Scale (DRS); presence of medical devices (e.g., for eating or breathing); occurrence and severity of medical complications.Results: patients in DoC, and particularly those in VS/UWS, showed severe overall clinical complexity. Anoxic patients had higher overall clinical complexity, lower level of responsiveness/consciousness, higher functional disability, and higher needs of medical devices. Vascular patients had worse premorbid clinical comorbidities. The two etiologies showed a comparable rate of MC, higher than that observed in traumatic etiology.Conclusion: overall clinical complexity is significantly higher in VS/UWS than in MCS, and in non-traumatic vs. traumatic etiology. These findings could explain the worse clinical evolution reported in anoxic and vascular etiologies and in VS/UWS patients and contribute to plan patient-tailored care and rehabilitation programmes.

Don't forget the jumper's knee in the young sportsman: evaluation of patellar tendinopathy with a high frequency ultrasound probe.

Patellar tendinopathy, or Jumper's knee, is a painful knee condition caused by inflammation of the patella tendon. This condition is most frequently observed in subjects who play sports that require repetitive regular jumping. Jumper's knee is frequently misdiagnosed as a minor injury and many athletes, like our patient, keep on training and competing and either tend to ignore the injury or attempt to treat it themselves. However, jumper's knee is a serious condition that requires a correct and timely diagnosis, which often necessitates ultrasound investigation in order to start the most appropriate treatment.

Declining incidence of intracerebral hemorrhage over two decades in a population-based study.

BACKGROUND AND PURPOSE: The incidence and case-fatality rate (CFR) of primary intracerebral hemorrhage (PICH) over two decades were assessed in a prospective population-based study. METHODS: Cases of incident first-ever PICH were recorded over a 2-year period (2011-2012) from multiple sources in the district of L'Aquila, central Italy. Included patients were followed up to 1 year after the event to ascertain CFRs. Current data were compared with those previously collected from 1994 through 1998. RESULTS: In all, 115 patients (52 men; 45.2%) with a first-ever PICH were included. Mean age ± SD was 77.4 ± 11.8 years. The hemorrhage was lobar in 43 (37.4%) patients, deep in 56 (48.7%), in the posterior fossa in 11 (9.6%) and intraventricular or multiple localized in five (4.3%). Crude annual incidence rate was 19.3 per 100 000 and 14.8 per 100 000 when standardized to the 2011 European population, indicating a 48% reduction comparing data of 2011-2012 to those of 1994-1998 (incidence rate ratio 0.52; 95% confidence interval 0.43-0.64; P < 0.001). In 2011-2012, the 7-day CFR was 27.8%, the 30-day CFR was 42.6% and the 1-year CFR was 52.2%; the 1-year standardized mortality ratio was 0.81 (95% confidence interval 0.63-1.04) compared with 1994-1998. CONCLUSIONS: The annual incidence rate of PICH was lower than that found two decades before and close to the rates recently found in other western countries. Data also indicated a non-significant trend towards a decrease in mortality, which nonetheless remained high, pointing to the need for more appropriate treatments in order to reduce PICH severity and mortality.

Migraine and risk of ischaemic heart disease: a systematic review and meta-analysis of observational studies.

BACKGROUND AND PURPOSE: Several studies have assessed the risk of ischaemic heart diseases in migraineurs, drawing different conclusions. To define and update the issue, a systematic review and meta-analysis of the available observational studies was performed. METHODS: PubMed and EMBASE were systematically searched up to April 2014 for observational studies dealing with the risk of any form of ischaemic heart disease in migraineurs. Studies assessing migraine as exposure and several types of ischaemic heart disease as outcomes were included in the analysis. A random effects model was used to pool the effect sizes. RESULTS: Out of 3348 records, 15 studies (one case-control, one cross-sectional and 13 cohort studies) were identified and were included in the meta-analysis. The pooled analysis indicated an increased risk of myocardial infarction (pooled adjusted effect estimate 1.33, 95% confidence interval 1.08-1.64; P = 0.007) and of angina (pooled adjusted effect estimate 1.29, 95% confidence interval 1.17-1.43; P < 0.0001) in migraineurs compared to non-migraineurs. CONCLUSIONS: Based on our data indicating an association of migraine with myocardial infarction and angina and on previous data showing an association of migraine, and particularly migraine with aura, with an increased risk for stroke, migraine can be appropriately considered an overall risk factor for cardiovascular diseases.

Insulin resistance in migraineurs: results from a case-control study.

OBJECTIVES: Several studies have suggested an association between migraine and insulin resistance (IR) without adequately addressing the issue according to migraine type. We assessed IR in subjects with migraine with aura (MwA) and migraine without aura (MwoA) to estimate the consistency of the possible association. METHODS: In a case-control study we included case subjects with MwA and MwoA, who were consecutively selected from those referred to our Regional Headache Center from September 2011 to February 2013, and age-matched control subjects selected using general practitioners' databases. IR was calculated by means of the homeostatic model assessment of IR (HOMA-IR), ß-cell function (HOMA-B), and the quantitative insulin sensitivity check index (QUICKI) measuring glucose and insulin values in a blood sample collected in the morning after overnight fasting. Data regarding anthropometric measures, comorbidity risk factors, and migraine characteristics were also recorded. RESULTS: We recruited 50 case subjects with MwA (38 women) and 50 with MwoA (40 women) and 50 control subjects (40 women). Proportions of arterial hypertension, cigarette smoking, hypercholesterolemia, use of oral contraceptives, and mean values of the body mass index (BMI) were similar in the three groups. We found significantly different glucose values among and within groups considering case subjects with MwA and MwoA and control subjects (4.9 ± 0.6 vs 4.7 ± 0.5 vs 4.6 ± 0.5 mmol/l; P = 0.018) in the absence of any difference in insulin (53.1 ± 24.0 vs 56.7 ± 34.4 vs 53.8 ± 24.4 pmol/l; P = 0.811), HOMA-IR (1.6 ± 0.8 vs 1.7 ± 1.0 vs 1.6 ± 0.7; P = 0.765), HOMA-B (121.4 ± 71.1 vs 149.2 ± 93.8 vs 162.8 ± 109.7; P = 0.107), and QUICKI (0.36 ± 0.03 vs 0.37 ± 0.03 vs 0.37 ± 0.03; P = 0.877) values. The logistic regression model showed increased odds of MwA in subjects exposed to the highest tertile of glucose values. This association was confirmed in the adjusted model, in which case subjects with MwA were compared with those with MwoA but not with control subjects. CONCLUSIONS: In contrast to what has been shown by the majority of the available studies, the results of our study do not support the association of migraine with IR. As our study was not population-based and several patients had low disease activity, these findings need further confirmation.

Cyclooxygenase and atherosclerosis: a smoking area.

Chronic smoking is associated with functional and structural vascular changes underlying inflammatory processes responsible for plaque formation and rupture. Cyclooxygenase (COX) is the key enzyme linking smoking action to inflammatory damages: it is responsible for the conversion of arachidonic acid to prostanoids, and lipid mediators involved in most of pathological processes. Two COX isoenzymes have been characterized, COX-1 and COX-2, that differ in terms of regulatory mechanisms of expression, tissue distribution, substrate specificity, and preferential coupling to upstream and downstream enzymes. The aim of this review is to highlight the pathogenetic role of chronic smoking in vasomotor dysfunction, inflammation, and modification of lipids underlying the initiation and the progression of atherosclerosis and to remark the hypothesis that plaque composition rather than plaque size is the real determinant of the plaque evolution toward rupture and the major responsible for acute ischemic syndromes. The concomitantly higher expression of EP4, COX-2, mPGES-1, MMP-2 and MMP-9 in unstable plaques is focused and the role of PGE(2) as pathophysiological link between smoking, COX-2 and MMP activity is stressed. Indeed, the intracellular pathways regulating COX-2 and the mechanisms suggested to clarify the role of COX-2 and downstream synthases in atherothrombosis are summarized.

Beta-amyloid: a disease target or a synaptic regulator affecting age-related neurotransmitter changes?

The amyloid cascade hypothesis sustains that beta-amyloid (Abeta) is the main pathogenetic factor of Alzheimer's Disease (AD). Although the direct and indirect neurotoxic role of Abeta are unchallenged, recent findings suggest that the peptide may have so far unforeseen physiological roles. In this regard, the observations showing the ability of Abeta to exert synaptic activities in absence of neurotoxicity are very intriguing. In particular, the peptide is able to affect synaptic transmission of different neurotransmitter systems in key brain areas that regulate executive and cognitive functions, an observation that points Abeta as a new neuromodulator. However, in a pathological context, Abeta may drive functional alterations of several neurotransmitter systems in the early phases of the disease, in turn producing subtle cognitive and behavioural disturbances in addition and before the well known neurodegenerative events. On the other hand, advancing age is the most significant risk factor for the development of AD. In fact, during aging increased Abeta levels have been reported. Moreover, several neurotransmitter systems undergo age-related changes in parallel to a decline of cognitive functions. However, the putative neuromodulatory role of Abeta in the context of aging is nowadays unknown. For these reasons, future studies about the spectrum of action of Abeta (brain areas and neurotransmitter systems affected) are particularly interesting since may suggest new therapeutic targets in order to sustain those functions which may be altered during aging.

Prevalence of Parkinson's disease in the L'Aquila district, central Italy.

OBJECTIVE: We estimated the prevalence of Parkinson's disease (PD) in the L'Aquila district. METHODS: Cases of PD were identified screening all available case sources including general practitioners and antiparkinsonian drug-users by means of pharmacy records. Prevalence of PD was computed considering the prevalence day of December 31, 2001. RESULTS: On the prevalence day, 682 patients with PD were alive and residing in the L'Aquila district. A total of 354 patients were women and 328 men. The overall crude prevalence rate was 229.3/100,000 (95% CI 212.7-247.1), without any difference between men (227.4/100,000; 95% CI 200.0-257.5) and women (231.1/100,000; 95% CI 202.2-263.1). Prevalence rates increased with age in both sexes and were higher in urban (244.5/100,000; 95% CI 213.7-278.5) than in rural residents (214.7/100,000; 95% CI 189.0-242.9) (SRR = 1.7; 95% CI 1.3-2.1). CONCLUSIONS: The prevalence of PD in the L'Aquila district was within the range of prevalence rates found in our country and steeply increased with advancing age in both sexes.

Does rifaximin prevent complications of diverticular disease? A retrospective study.

While the treatment of complicated diverticular disease (DD) is standardized, the approach to the symptomatic DD and prevention of relapsing complicated DD is still debated. An open question is whether nonabsorbable antibiotics may reduce the incidence of major complications of DD. We wanted to retrospectively analyze the prevalence of this disease in a large population of patients undergoing colonoscopy in our center in the last 10 years. Patients with symptomatic or complicated DD were treated with rifaximin 1,200 mg/die for 10-12 days during the acute phase in addition to the appropriate systemic antibiotics, followed by a prophylactic regimen with 800 mg/die for 7 days every month. The patients were followed up to December 2003, and the incidence of new complications and the relapses of symptomatology were determined. A total of 11,344 patients were screened. Of them, 2,287 showed an anatomical diverticulosis, and 408 had a diagnosis of complicated DD. The results indicate that the prevalence of DD--either in the uncomplicated or complicated form--in our area (Abruzzo, Italy) is identical to that of European countries, whose diet is characterized by a low amount of fiber and a high content of calories and refined sugars. Along a period of 10 years, a relapsing symptomatology of DD was observed in 112 patients treated with rifaximin (4.89%), while new complications of the DD were observed in 27 patients (1.18%). The comparison of these data with those of larger published series suggests a possible role of rifaximin in the prevention of DD main complications.

[Endoscopic diagnosis and treatment of juvenile solitary polyps, in the light of the unusual but proven neoplastic potential]. / Considerazioni di diagnosi e terapia endoscopica dei polipi giovanili solitari, alla luce della rara ma dimostrata potenzialità neoplastica.

For many years a neoplastic potentiality of the juvenile polyps has been denied. The authors performed a critical review of the international literature about the neoplastic transformation of the juvenile polyps. Each examined case had to respect three conditions: 1) exhaustive hystological findings certifying a clear neoplastic degeneration of a juvenile polyp; 2) clear evidence of single juvenile polyposis (< 5), presence in the colon and rectum only and absence of familiarity; 3) reliable diagnostic practice (endoscopic and/or hystological evidence). During the review we collected 271 cases of juvenile polyposis observed in 12 countries, 97 of which (35.79%) showed neoplastic transformation, adenomatous type in 50 (18.45%) and carcinomatous type in 47 (17.34%), and 13 cases of neoplastic degeneration of single juvenile polyps. The review shows clearly and strongly that the risk of cancer in the juvenile polyposis can reach the risk of the adenomatous polyposis. The neoplastic degeneration exists in the single juvenile polyps even if in a lower degree.

The role of xenon CT measurements of cerebral blood flow in the clinical determination of brain death.

The demonstration of absent blood flow to the brain is often used as a confirmatory test of brain death. Traditionally, cerebral angiography and dynamic radionuclide brain scanning have been used for this purpose. Recently, xenon CT cerebral blood flow techniques have been developed and applied to a wide variety of clinical problems, including the confirmation of brain death. We report our experience with xenon CT studies performed over a 7-year period (1983-1989) in 30 patients with brain injuries. These patients met clinical criteria for brain death within 24 hr of the study. Twenty patients had average global flow values of less than 5 ml/100 ml/min. Seven patients demonstrated mixed flow patterns, whereby large areas of brain showed flow values of less than 5 ml/100 ml/min and residual pockets of flow greater than 5 ml/100/ml/min. Globally symmetric normal to hyperemic flows were seen in three patients. Our study suggests that the demonstration of average global flows of less than 5/ml/100 ml/min is confirmatory of brain death. Demonstration of persistent flow to the entire brain or regions of the brain is not diagnostic of brain death but also does not exclude such an outcome in patients with severe brain injuries. Xenon-derived flow information may be clinically useful in determining the patient's prognosis and in counseling the patient's family.

Contrast material in posterior vaginal fornix mimicking bladder rupture: CT features.

Abdominopelvic CT of a 22-year-old woman who sustained blunt abdominal trauma revealed a collection of contrast material posterior to the bladder. This CT appearance was interpreted as evidence of bladder rupture, despite previously performed normal retrograde cystography. Subsequent urologic studies confirmed the absence of bladder injury. Retrospective review of CT revealed that collection was within the vagina. This case demonstrates an important false-positive CT diagnosis of bladder rupture and confirms the importance of retrograde cystography for the diagnosis of bladder rupture.