Attitudes of Italian Infertile Women Toward Ethical and Regulatory Limits of Medically Assisted Procreation (MAP).

Objective: Outline the views of Italian women, with fertility problems, on Medically Assisted Procreation. Methods: We have collected the opinions of 448 infertile women. The items used in the questionnaire were created with a qualitative method based on the Medically Assisted Procreation's most important bioethics issues and on the basis of the limits imposed by Law. The questions of the first part of the questionnaire were open; in the second part was closed ("Yes/No"); for each method they were asked whether they would introduce a legal limit to prohibit it. The tests have been standardized with test-retest method. Results: We found that much of the disputes that have, over time, been made to Law 40 of 2004 by Italian Courts, are shared by patients with infertility problems. Italian women do not share the legal limit for Medically Assisted Procreation in over 43 women, heterologous in-semination with seed donation and egg donation. Moreover, our sample show that Italian women do not share legal limit to pre-implantation genetic diagnosis and cryopreservation of embryos. Moreover, it emerges that many Italian infertile patients disagree with the Medically Assisted Procreation for homosexual couples. Conclusion: It will be important, in the event of a legislative reform in Italy on the Medically Assisted Procreation, also consider the point of view of women with infertility problems.

Defining the transcriptomic and proteomic profiles of rat ageing skeletal muscle by the use of a cDNA array, 2D- and Blue native-PAGE approach.

We defined the transcriptomic and proteomic profiles of rat ageing skeletal muscle using a combined cDNA array, 2D- and Blue native-PAGE approach. This was allowed to obtain an overview of the interrelated events leading to the transcriptome/proteome/mitoproteome changes likely to underlie the structural/metabolic features of aged skeletal muscle. The main differences were found in genes/proteins related to energy metabolism, mitochondrial pathways, myofibrillar filaments, and detoxification. Concerning the abundance of mitochondrial OXPHOS complexes as well as their supramolecular organization and activity, mitochondria from old rats, when compared with those from young rats, contained significantly lower amounts of complex I (NADH:ubiquinone oxidoreductase), V (FoF1-ATP synthase), and III (ubiquinol:cytochrome c oxidoreductase). The same mitochondria contained a significantly larger amount of complex II (succinate:ubiquinone oxidoreductase), but an unchanged amount of complex IV (cytochrome c oxidase, COX). When comparing the supercomplex profiles between young and old muscle mitochondria, the densitometric analysis revealed that lighter supercomplexes were significantly reduced in older mitochondria, and that in the older group the major supercomplex bands were those representing heavier supercomplexes, likely suggesting a compensatory mechanism that, in ageing muscle, is functionally directed towards substrate channeling and catalytic enhancement advantaging the respirosome.

Tethered cord syndrome.

AIM: Tethered cord syndrome (TCS) is a stretch-induced disorder of the spinal cord. Tethering is due to an inelastic structure anchoring the caudal end of the spinal cord as a short and thick filum terminale. Spinal dysraphism is occasionally associated,but the etiological relationship between these disorders remain unclear. Other anomalies may be concurrently found as hydromielia and Arnold-Chiari malformation. METHODS: The authors analysed neuroradiological findings in 5 children and 9 patients of 20-24 years of age; there were four male and ten female. The criteria for inclusion were neurological disturbances (disorders!) localizable to the level of the conus and evidence for spinal dysraphism. The purpose of this study was to make the precise diagnosis and make also precise planning for therapy, conservative or surgical treatment. RESULTS: The age of diagnosis of TCS varies from under 1 year to 14 years and is very rarely as late as adulthood. TCS can present late and insidiously with progressive gait disturbances, atrophy of various muscle groups or the entire limb, loss of reflexes,loss of sensation in the sacral dermatomes, sphincter disturbances, gait abnormality and pain in the gluteal, perianal and other pelvic areas. The diagnosis involves standard X-RAY examination, CT and CT-Mielography but MRI is now a diagnostic method of choice. Surgical untethering of the cord is recommended. The associated pain responds best to surgical treatment; ambulation and bladder function may improve as well. CONCLUSIONS: However sphincter dysfunction often remains a permanent problem. Given the potential for rapid deterioration with incomplete neurological recovery, even prophilactic surgery seems advisable. The patient need to be followed up, if not operated upon.

Post traumatic retropharyngeal pseudomeningocele.

The authors report a case of a 33-year-old man who presented, during recovery from coma due to severe head injury, dysphagia and respiratory failure. Magnetic resonance, retrograde radionuclide myelography and computerized tomographic myelography identified a pseudomeningocele in the retropharyngeal space due to a tear of the left C2 radicular sleeve. After failed medical management, the patient underwent lumbo peritoneal shunt. Magnetic resonance controls showed progressive collapse of the collection. After 3 months the patient was able to breathe spontaneously and to swallow. The authors describe pathogenesis, diagnostic strategy and principles of treatment of traumatic retropharyngeal pseudomeningoceles.

Radiation leukoencephalopathy associated with moderate hydrocephalus: intracranial pressure monitoring and results of ventriculoperitoneal shunting.

Delayed neurological sequelae of radiotherapy have several manifestations; leukoencephalopathy is one of the most common. Pathogenetic relationships between radiation leukoencephalopathy and other findings of diffuse radiation injury (brain atrophy and progressive ventriculomegaly) are not well defined. Moreover, no guidelines have been established for the treatment of hydrocephalus when associated with radiation leukoencephalopathy. Our study reports intracranial pressure (ICP) monitoring in two patients with radiation leukoencephalopathy with moderate hydrocephalus. High intraventricular mean pressure and high peaks were found, and marked improvement of clinical status after shunting was achieved. This study, although restricted to only two patients, shows that ventriculoperitoneal shunting insertion is useful in radiation-induced hydrocephalus, when ICP monitoring detects high mean pressure. A hypothesis is advanced concerning radiation-induced hydrocephalus with high ICP, emphasizing periventricular astrocytosis and its connections with cerebral compliance.

Antibiotic prophylaxis in clean neurosurgery.

Two regimens of antibiotic prophylaxis are in use at our institution. These protocols consist in perioperative administration of a single dose of amoxicillin-clavulanic acid of 2.2 g at induction and 8 h later and irrigation of the surgical wound with rifamycin before closure. In cases of dirty surgery, placement of external shunts or foreign bodies, we administer vancomycin 1.5 g/die and ceftazidime 6 g/die for 72 h. A retrospective study of all the clean operations we performed in the last 2 years yielded a total of 793 consecutive procedures with three postoperative wound infections. These results are in agreement with the majority of series reported in literature, although different prophylactic protocols are applied and in some cases no prophylactic antibiotics are administered at all. The use of these agents in clean neurosurgery remains, as a matter of fact, controversial. In order to further investigate this issue we took three or more intraoperative samples for culture in 40 clean cases. Only in 2% of these samples were cultures positive. Although lacking statistical significance, these results are interesting indications of the appropriateness of antimicrobial prophylaxis in clean neurosurgery and invite further investigation in that direction.

2-thiouracil is a selective inhibitor of neuronal nitric oxide synthase antagonising tetrahydrobiopterin-dependent enzyme activation and dimerisation.

2-thiouracil (TU), an established antithyroid drug and melanoma-seeker, was found to selectively inhibit neuronal nitric oxide synthase (nNOS) in a competitive manner (K(i)=20 microM), being inactive on the other NOS isoforms. The drug apparently interfered with the substrate- and tetrahydrobiopterin (BH(4))-binding to the enzyme. It caused a 60% inhibition of H(2)O(2) production in the absence of L-arginine and BH(4), and antagonised BH(4)-induced dimerisation of nNOS, but did not affect cytochrome c reduction. These results open new perspectives in the understanding of the antithyroid action of TU and provide a new lead structure for the development of selective nNOS inhibitors to elucidate the interdependence of the substrate and pteridine sites and to modulate pathologically aberrant NO formation.

Relationship of insulin resistance and hyperinsulinemia to blood pressure during pregnancy.

The purpose of our study was to examine the relationship between insulin resistance and blood pressure during pregnancy and to determine to what extent insulin resistance is related to the subsequent development of pregnancy-induced hypertension. The study population consisted of 292 women who had serum insulin, glucose and insulin-glucose ratios determined at 26-28 weeks gestation in a fasting state and 1 hr after a 50-g oral glucose challenge. These were compared with blood pressures at 26-28 weeks gestation and in the late third trimester. A statistically significant correlation exists overall between (1) blood pressure at 26-28 weeks gestation and both fasting insulin and insulin-glucose ratios, as well as (2) systolic blood pressure at term and fasting insulin levels. However, when controlled for confounding variables including body mass index, race and age, no statistically significant relationship remained. The metabolic variables in patients with pregnancy-induced hypertension were not statistically different from the normotensive patients. In conclusion, this study demonstrates that insulin resistance and hyperinsulinemia are not major determinants of blood pressure during pregnancy.

Spinal meningiomas in pregnancy: report of two cases and review of the literature.

Although meningiomas of the spinal district are frequently found, first presentation of these growths during pregnancy is extremely rare. Few cases have been reported in the literature up to now. In a series of 122 spinal meningiomas operated-on at our institution over the period 1962-1994, first neurological symptoms and signs became evident during pregnancy in two cases. Considering this noteworthy, the hydrodynamic and hormone-mediated mechanisms regarding meningioma growth during pregnancy and a review of the pertinent literature are discussed.

Transient "cerebellar" mutism in lesions of the mesencephalic-cerebellar region.

Four patients aged from 20 to 48 years with transient mutism are presented: 3 patients underwent surgery for midline tumours of the mesencephalic-cerebellar region (medulloblastoma in two cases and pinealoblastoma in one), at times attached to one or both lateral recesses of the IV ventricle. One patient was hospitalized and treated for brain-stem ischemia. All patients developed mutism 48 to 72 hours after surgery; in the patient with brain-stem softening mutism appeared 72 hours after admission. All the patients had unimpaired consciousness and no deficits of lower cranial nerves. Speech, always normal in the first hours after surgery, was regained after a period of 6-16 weeks. Various hypotheses for this speech disorder are analyzed.

Cavernous angioma does not exist?

12 cases of cerebral "venous angioma" are reported; pathological, clinical and radiological features of the lesion are reviewed. "Venous angioma" should be regarded as a developmental anatomic variation of the venous drainage system of the white matter. Its clinical significance is controversial, although it has been reported to cause hemorrhage, seizures, progressive neurological deficits, headaches. The clinical presentation of our patients was variable and, in some of them, dependent also on associated lesions. An hematoma was found in three patients, infarction in one and tumor in one. Angiography, CT and MRI demonstrated the typical appearance of the anomaly. Surgery was performed in one patient harboring a significant cerebellar hematoma and the coexistence of a cavernoma was pathologically confirmed. Venous developmental anomalies are often identified as the source of symptoms due to other conditions, that should be treated independently sparing the anomaly.

[Hypertensive pneumocephalus, postoperative complication of chronic subdural hematomas]. / Pneumocefalo iperteso, complicanza post-operatoria degli ematomi sottodurali cronici.

The authors report 3 cases of subdural tension pneumocephalus developed after surgery for subdural chronic hematomas. The mechanisms involved in the pathogenesis of this complication are discussed; the importance of the computed tomography in the assessment of the subdural tension pneumocephalus is stressed. Surgery is always indicated in cases of increased tension of the air collection and generally resolves the neurological deficits.

[Postoperative lumbar discitis]. / Le disciti lombari post-operatorie.

The authors report our experience on 19 cases of discitis developed after operations for herniated lumbar disc. Because of the negativity of the neuroradiological studies in the acute stage, the recognition of the typical syndrome (severe back pain, spasm of the paravertebral lumbar muscles, limited spinal motility, fever) beginning 3-30 days post-operatively and the study of some laboratory tests (elevated Erythrocyte sedimentation rate (ESR) and midly to moderately elevated white blood cells (WBC) are very important for diagnosis. The first radiographic findings (disc space narrowing, ecc.) are detectable only 4 to 6 weeks after the first symptoms; other X-ray findings are not seen post-operatively before 6 months-2 years. The CT-scan is diagnostic of discitis only when the following three specific signs are present: a) anterior paravertebral soft tissue swelling with obliteration of paravertebral fat planes; b) fragmentation or erosion of vertebral end plates; c) paravertebral fluid collection (abscess). In our experience a period of immobilization of the spine with a plaster body jackets and the use of adequate antibiotic therapy are the more effective treatment. Undoubtedly the discits are the results of an infection that must be prevented adhering to the aseptic principles not only during surgery but also during the procedures performed in the radiology suite.

Surgical indications for intracranial arachnoid cysts.

Diagnostic work-up and management of intracranial arachnoid cysts are still controversial. The authors have standardized a therapeutic protocol based on the information derived from CSF contrast flow studies. The report concerns 16 cases of intracranial arachnoid cysts treated according to their protocol.

Treatment of cerebral arteriovenous malformations with a combination of preoperative embolization and surgery.

Forty-nine patients with cerebral arteriovenous malformations (AVMs) were treated with preoperative embolization followed by resection using a microsurgical approach. In 27 patients, the AVM was located in an eloquent area; in 32 patients, the volume of the AVM was over 20 cm3. Preoperatively, flow-directed embolization was performed in 10 patients (28 procedures), selective embolization with threads was performed in 35 patients (46 procedures), and a combination of flow-directed and selective embolization was performed in 4 patients (12 procedures). The percentage of reduction of the AVM volume averaged 36% after embolization. Five minor complications (transient neurological deficits, in 2 cases associated with ischemic areas on the CT scan) were observed after embolization. The interval between the last embolization and surgery was as follows: within 10 days in 7 patients; between 11 and 20 days in 3 patients; between 21 and 30 days in 10 patients; between 31 and 60 days in 11 patients; and 2 months later in 18 patients. The efficacy of this combined treatment (embolization plus surgery) was evaluated by the incidence of hyperemic complications and the clinical outcome. Hyperemic complications occurred more frequently in patients with an AVM volume greater than 20 cm3. When compared with flow-directed embolization, selective embolization was linked with decreased bleeding during surgery; postoperatively, the incidence of cerebral edema was also lower. Clinical outcome was better after selective embolization, with no occurrence of major deficits and no mortality. When the percentage of reduction of the AVM volume after embolization was 40% or more, the incidence of intraoperative hyperemic complications was lower; moreover, new permanent deficits were never observed in patients with this volume reduction. A retrospective clinical comparison of two groups of patients with similar AVM volumes (greater than 20 cm3)--those given combined treatment (n = 32) versus those treated by direct surgery alone (n = 27)--showed that intraoperative bleeding appeared to decrease in patients treated by embolization; the incidence of postoperative hyperemic complications was not different in the two groups. New major deficits and deaths were less frequent in patients treated by embolization (P = 0.05 for the incidence of major deficits); postoperative epilepsy was also less common in these patients. In conclusion, combined treatment with selective preoperative embolization and direct surgery may help the neurosurgeon in the treatment of large, high-flow AVMs, reducing the risks connected with their surgical removal.

The relevance of anatomic and hemodynamic factors to a classification of cerebral arteriovenous malformations.

Potential prognostic anatomic and hemodynamic factors were evaluated in 248 patients with cerebral arteriovenous malformations (AVMs), all treated by direct microsurgical removal. The size of each AVM was calculated by its volume, obtained by the multiplication of the three AVM diameters by 0.52. A surgical classification of AVM location (in 11 groups) is proposed. Types of feeders and of drainage were classified as superficial or deep; the extent of the drainage system was classified according to a four-degree scale. The mean flow velocity in the main AVM feeder, detected using transcranial Doppler ultrasonography, was used as an indirect measure of AVM shunt flow in a small number of patients (n = 29). AVM volume was a very important prognostic factor: the incidence of hyperemic complications and the morbidity and mortality rate were significantly higher when the volume of the lesion was greater than 20 cm3 (P less than 0.0001 for hyperemic complications; P less than 0.001 for permanent morbidity and mortality). The incidence of hyperemic complications and the morbidity rate were higher in AVMs in rolandic, inferior limbic, and insular locations than in AVMs in other locations. As for other anatomic factors: a) the presence of deep feeders significantly increased the incidence of hyperemic complications, as well as the morbidity and mortality rate; b) the presence of deep drainage significantly increased permanent morbidity only; c) the extension of the venous system was significantly related to the development of hyperemic complications, and to morbidity and mortality. Transcranial Doppler examination showed that mean flow velocities greater than 120 cm/s in the main feeder were associated with a significantly higher rate of postoperative hematomas and transient deficits. A classification of cerebral AVMs that takes into account AVM volume and location, the type of feeders, the extent of the drainage system, and the main feeder flow velocity is suggested.

Subarachnoid haemorrhage of unknown origin: clinical and tomographical aspects.

65 patients with negative but technically satisfactory 4 vessel angiography - all admitted to our Department in the years 1976-1983 - were evaluated in the present study. CT scan was undertaken in all cases (in 47 cases within 4 days of haemorrhage). Arterial hypertension was present on admission in 9% of cases. The period of follow-up ranged from 4 to 11 years, with a mean of 5.3 years. The study group was compared to a control group, comprising 760 patients with subarachnoid haemorrhage from ruptured aneurysms, admitted during the same period. Clinical grade on admission (Hunt's classification) was better in patients belonging to the study group. The amount of cisternal deposition on CT scan was less significant than in patients with ruptured aneurysms, and the deposition was often atypical (circumpeduncular, ambiental, and/or tentorial). Clinical deterioration associated with vasospasm was observed in 5% of patients in this study and in 27% of patients in the control group. In patients with a consistent or thick cisternal layer (CT scan "at risk") the incidence of clinical vasospasm was 21%, against 47% in controls. One or more rebleedings occurred in 12% of patients in the study group, against 25% of patients in the control group. A significant ventricular dilatation was observed in 15% of patients in the first group (requiring a shunt in 8%), against 25% of patients in the second group (requiring a shunt in 11%). Final outcome was favourable in 95% of patients in this study group and in 63% of patients in the control group, with a mortality rate of 5% in the first group and 32% in the second group.

Cavernous sinus meningiomas.

Analysing 12 cases of cavernous sinus meningiomas the authors conclude that: the clinical history is characteristic; CT scan has proved to be more sensitive than carotid angiography in detecting small lesions. However in large lesions the vascular supply pattern is the only feature that exactly identifies the site of the lesion. Both angiography and CT scan allow a near definitive diagnosis of meningioma; because of their location it is almost always impossible to remove these tumours completely. Actually the best treatment is a piecemeal subtotal microsurgical removal via a subtemporal approach. Radiotherapy is indicated for partially resected lesions. On the basis of the revision of the anatomy of this region and looking forward to a widespread use of the Cavitron in neurosurgery, a more radical approach to this lesion is foreseen.