Comparison of image quality and diagnostic efficacy of routine clinical lumbar spine imaging at 0.55T and 1.5/3T.

PURPOSE: To compare image quality, assess inter-reader variability, and evaluate the diagnostic efficacy of routine clinical lumbar spine sequences at 0.55T compared with those collected at 1.5/3T to assess common spine pathology. METHODS: 665 image series across 70 studies, collected at 0.55T and 1.5/3T, were assessed by two neuroradiology fellows for overall imaging quality (OIQ), artifacts, and accurate visualization of anatomical features (intervertebral discs, neural foramina, spinal cord, bone marrow, and conus / cauda equina nerve roots) using a 4-point Likert scale (1 = non-diagnostic to 4 = excellent). For the 0.55T scans, the most appropriate diagnosis(es) from a picklist of common spine pathologies was selected. The mean ± SD of all scores for all features for each sequence and reader at 0.55T and 1.5/3T were calculated. Paired t-tests (p ≤ 0.05) were used to compare ratings between field strengths. The inter-reader agreement was calculated using linear-weighted Cohen's Kappa coefficient (p ≤ 0.05). Unpaired VCG analysis for OIQ was additionally employed to represent differences between 0.55T and 1.5/3T (95 % CI). RESULTS: All sequences at 0.55T were rated as acceptable (≥2) for diagnostic use by both readers despite significantly lower scores for some compared to those at 1.5/3T. While there was low inter-reader agreement on individual scores, the agreement on the diagnosis was high, demonstrating the potential of this system for detecting routine spine pathology. CONCLUSIONS: Clinical lumbar spine imaging at 0.55T produces diagnostic-quality images demonstrating the feasibility of its use in diagnosing spinal pathology, including osteomyelitis/discitis, post-surgical changes with complications, and metastatic disease.

Exantema en enfermedad por virus de inmunodeficiencia humana, ¿manifestación de infección o reacción alérgica?

Paciente varón que presentó exantema maculopapular, no pruriginoso, sin afectación palmoplantar, luego de recibir tratamiento con trimetoprim/sulfametoxazol por siete días debido a sintomatología gastrointestinal. Tras realizar historia clínica completa y con pruebas de cuarta generación se confirmó infección por VIH. Al quinto día de tratamiento antirretroviral presentó nuevas lesiones eritematosas con descamación gruesa, pruriginosas, edema facial y eosinofilia. Se realizó una biopsia de piel que reportó una dermatitis liquenoide, con espongiosis, degeneración vacuolar de la capa basal, queratinocitos necróticos e infiltrado de eosinófilos, características que favorecen la reacción por drogas. El tratamiento consistió en interrumpir la terapia combinada, uso de corticoides sistémicos, antihistamínicos y ya que, no se trató de un cuadro severo, se reinició el tratamiento antirretroviral sin complicaciones.

A male patient presented with a maculopapular, non-pruritic rash, without palmoplantar involvement, after receiving treatment with trimethoprim/sulfamethoxazole for seven days due to gastrointestinal symptoms. After taking a complete medical history and using fourth-generation tests confirmed HIV infection. On the fifth day of antiretroviral treatment, he presented new erythematous lesions with thick, pruritic scaling, facial edema and eosinophilia. A skin biopsy reported lichenoid dermatitis, with spongiosis, vacuolar degeneration of the basal layer, necrotic keratinocytes and eosinophil infiltrate, characteristics that favor drug reaction. The treatment consisted of interrupting the combined therapy, using systemic corticosteroids, antihistamines and since it was not a severe condition, antiretroviral treatment restarted without complications.

Quality assessment of routine brain imaging at 0.55 T: initial experience in a clinical workflow.

The purpose of this study was to assess the quality of clinical brain imaging in healthy subjects and patients on an FDA-approved commercial 0.55 T MRI scanner, and to provide information about the feasibility of using this scanner in a clinical workflow. In this IRB-approved study, brain examinations on the scanner were prospectively performed in 10 healthy subjects (February-April 2022) and retrospectively derived from 44 patients (February-July 2022). Images collected using the following pulse sequences were available for assessment: axial DWI (diffusion-weighted imaging), apparent diffusion coefficient maps, 2D axial fluid-attenuated inversion recovery images, axial susceptibility-weighted images (both magnitude and phase), sagittal T1 -weighted (T1w) Sampling Perfection with Application Optimized Contrast images, sagittal T1w MPRAGE (magnetization prepared rapid gradient echo) with contrast enhancement, axial T1w turbo spin echo (TSE) with and without contrast enhancement, and axial T2 -weighted TSE. Two readers retrospectively and independently evaluated image quality and specific anatomical features in a blinded fashion on a four-point Likert scale, with a score of 1 being unacceptable and 4 being excellent, and determined the ability to answer the clinical question in patients. For each category of image sequences, the mean, standard deviation, and percentage of unacceptable quality images (<2) were calculated. Acceptable (rating ≥ 2) image quality was achieved at 0.55 T in all sequences for patients and 85% of the sequences for healthy subjects. Radiologists were able to answer the clinical question in all patients scanned. In total, 50% of the sequences used in patients and about 60% of the sequences used in healthy subjects exhibited good (rating ≥ 3) image quality. Based on these findings, we conclude that diagnostic quality clinical brain images can be successfully collected on this commercial 0.55 T scanner, indicating that the routine brain imaging protocol may be deployed on this system in the clinical workflow.

Pathogenesis of spinal intramedullary lipomas: two case reports.

BACKGROUND: Spinal lipomas not associated with dysraphism are rare and have an unknown natural history. In this report, we describe two cases; they showed recurrence during long-term follow-up, which makes us doubt a benign malformative etiology. CASE REPORTS: Two patients, a 19-year-old South American woman and a 14-year-old boy with spinal lipomas, underwent surgical resection. The lipomas were not associated with dysraphism and were located in the cervicothoracic and craniocervical junctions. In both cases, we decided to operate due to clinical progression; the former had a progressive natural course, and the latter experienced clinical worsening after recurrence from previous surgeries. The surgery took place with the assistance of neurophysiological monitoring and intraoperative ultrasound; a partial resection and medullary decompression were done, following the more recent recommendations. DISCUSSION: The natural history of these lesions is currently unknown due to their rarity and the heterogeneity in the long-term follow-up of previously reported cases. Although previous reports describe good outcomes after surgical resection, long follow-ups, especially in young subjects, may show differences in these outcomes with progression and recurrence. We contribute to this last piece of evidence by describing two more cases of progression and recurrence. LESSONS: Long-term close follow-up should be done in young subjects with spinal lipomas, as they are more prone to an aggressive course. Metabolism and hormonal changes may be behind this progression. Reoperation must be considered if neurological decline is detected.

Association Between Ocular Trauma and Activation of Ocular Toxoplasmosis.

PURPOSE: To evaluate the association between ocular trauma and activation of ocular toxoplasmosis. METHODS: Retrospective review of 686 patients with ocular toxoplasmosis and its association with trauma to the eye or the head within 1 week of activation. RESULTS: Ten patients with a history of trauma and activation of ocular toxoplasmosis were detected (10/686; 1.45%). Nine patients showed a primary focus of retinitis without a previous scar and one patient had a recurrent form of ocular toxoplasmosis. From these 10 patients, Toxoplasma IgG was positive in eight of them. The median age of the patients was 35.8 years-old (range 17 to 65). CONCLUSIONS: These cases suggest that trauma can be associated with activation of retinal bradyzoite cysts in ocular toxoplasmosis.

Trotabresib, an oral potent bromodomain and extraterminal inhibitor, in patients with high-grade gliomas: A phase I, "window-of-opportunity" study.

BACKGROUND: The bromodomain and extraterminal protein (BET) inhibitor trotabresib has demonstrated antitumor activity in patients with advanced solid tumors, including high-grade gliomas. CC-90010-GBM-001 (NCT04047303) is a phase I study investigating the pharmacokinetics, pharmacodynamics, and CNS penetration of trotabresib in patients with recurrent high-grade gliomas scheduled for salvage resection. METHODS: Patients received trotabresib 30 mg/day on days 1-4 before surgery, followed by maintenance trotabresib 45 mg/day 4 days on/24 days off after surgery. Primary endpoints were plasma pharmacokinetics and trotabresib concentrations in resected tissue. Secondary and exploratory endpoints included safety, pharmacodynamics, and antitumor activity. RESULTS: Twenty patients received preoperative trotabresib and underwent resection with no delays or cancelations of surgery; 16 patients received maintenance trotabresib after recovery from surgery. Trotabresib plasma pharmacokinetics were consistent with previous data. Mean trotabresib brain tumor tissue:plasma ratio was 0.84 (estimated unbound partition coefficient [KPUU] 0.37), and modulation of pharmacodynamic markers was observed in blood and brain tumor tissue. Trotabresib was well tolerated; the most frequent grade 3/4 treatment-related adverse event during maintenance treatment was thrombocytopenia (5/16 patients). Six-month progression-free survival was 12%. Two patients remain on treatment with stable disease at cycles 25 and 30. CONCLUSIONS: Trotabresib penetrates the blood-brain-tumor barrier in patients with recurrent high-grade glioma and demonstrates target engagement in resected tumor tissue. Plasma pharmacokinetics, blood pharmacodynamics, and safety were comparable with previous results for trotabresib in patients with advanced solid tumors. Investigation of adjuvant trotabresib + temozolomide and concomitant trotabresib + temozolomide + radiotherapy in patients with newly diagnosed glioblastoma is ongoing (NCT04324840).

State-of-the-art magnetic resonance imaging sequences for pediatric body imaging.

Longer examination time, need for anesthesia in smaller children and the inability of most children to hold their breath are major limitations of MRI in pediatric body imaging. Fortunately, with technical advances, many new and upcoming MRI sequences are overcoming these limitations. Advances in data acquisition and k-space sampling methods have enabled sequences with improved temporal and spatial resolution, and minimal artifacts. Sequences to minimize movement artifacts mainly utilize radial k-space filling, and examples include the stack-of-stars method for T1-weighted imaging and the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER)/BLADE method for T2-weighted imaging. Similarly, the sequences with improved temporal resolution and the ability to obtain multiple phases in a single breath-hold in dynamic imaging mainly use some form of partial k-space filling method. New sequences use a variable combination of data sampling methods like compressed sensing, golden-angle radial k-space filling, parallel imaging and partial k-space filling to achieve free-breathing, faster sequences that could be useful for pediatric abdominal and thoracic imaging. Simultaneous multi-slice method has improved diffusion-weighted imaging (DWI) with reduction in scan time and artifacts. In this review, we provide an overview of data sampling methods like parallel imaging, compressed sensing, radial k-space sampling, partial k-space sampling and simultaneous multi-slice. This is followed by newer available and upcoming sequences for T1-, T2- and DWI based on these other advances. We also discuss the Dixon method and newer approaches to reducing metal artifacts.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study.

OBJECTIVES: The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery. DESIGN: This was an observational retrospective study. SETTINGS: A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020. PARTICIPANTS: A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection. RESULTS: More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic. CONCLUSIONS: Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Stratification of radiosensitive brain metastases based on an actionable S100A9/RAGE resistance mechanism.

Whole-brain radiotherapy (WBRT) is the treatment backbone for many patients with brain metastasis; however, its efficacy in preventing disease progression and the associated toxicity have questioned the clinical impact of this approach and emphasized the need for alternative treatments. Given the limited therapeutic options available for these patients and the poor understanding of the molecular mechanisms underlying the resistance of metastatic lesions to WBRT, we sought to uncover actionable targets and biomarkers that could help to refine patient selection. Through an unbiased analysis of experimental in vivo models of brain metastasis resistant to WBRT, we identified activation of the S100A9-RAGE-NF-κB-JunB pathway in brain metastases as a potential mediator of resistance in this organ. Targeting this pathway genetically or pharmacologically was sufficient to revert the WBRT resistance and increase therapeutic benefits in vivo at lower doses of radiation. In patients with primary melanoma, lung or breast adenocarcinoma developing brain metastasis, endogenous S100A9 levels in brain lesions correlated with clinical response to WBRT and underscored the potential of S100A9 levels in the blood as a noninvasive biomarker. Collectively, we provide a molecular framework to personalize WBRT and improve its efficacy through combination with a radiosensitizer that balances therapeutic benefit and toxicity.

A clinically compatible drug-screening platform based on organotypic cultures identifies vulnerabilities to prevent and treat brain metastasis.

We report a medium-throughput drug-screening platform (METPlatform) based on organotypic cultures that allows to evaluate inhibitors against metastases growing in situ. By applying this approach to the unmet clinical need of brain metastasis, we identified several vulnerabilities. Among them, a blood-brain barrier permeable HSP90 inhibitor showed high potency against mouse and human brain metastases at clinically relevant stages of the disease, including a novel model of local relapse after neurosurgery. Furthermore, in situ proteomic analysis applied to metastases treated with the chaperone inhibitor uncovered a novel molecular program in brain metastasis, which includes biomarkers of poor prognosis and actionable mechanisms of resistance. Our work validates METPlatform as a potent resource for metastasis research integrating drug-screening and unbiased omic approaches that is compatible with human samples. Thus, this clinically relevant strategy is aimed to personalize the management of metastatic disease in the brain and elsewhere.

Clinical improvement after cranioplasty and its relation to body position and cerebral hemodynamics.

Cranioplasty after decompressive craniectomy (DC) has been found to improve the neurological condition. The underlying mechanisms are still unknown. The aim of this study is to investigate the roles of the postural changes and atmospheric pressure (AP) in the brain hemodynamics and their relationship with clinical improvement. Seventy-eight patients were studied before and 72 h after cranioplasty with cervical and transcranial color Doppler ultrasound (TCCS) in the sitting and supine positions. Craniectomy size, shape, and force exerted by the AP (torque) were calculated. Neurological condition was assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Barthel index. Twenty-eight patients improved after cranioplasty. Their time elapsed from the DC was shorter (214 vs 324 days), preoperative Barthel was worse (54 vs 77), internal carotid artery (ICA) mean velocity of the defect side was lower while sitting (14.4 vs 20.9 cm/s), and torque over the craniectomy was greater (2480.3 vs 1464.3 N*cm). Multivariate binary logistic regression showed the consistency of these changes. TCCS findings were no longer present postoperatively. Lower ICA (defect side) velocity in the sitting position correlates significantly with clinical improvement. Greater torque exerted by the AP might explain different susceptibilities to postural changes, corrected by cranioplasty.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain.

OBJECTIVE: To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. SETTINGS: The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. PARTICIPANTS: This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. INTERVENTIONS: An exploratory factorial analysis was performed to select the most relevant variables of the sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. RESULTS: Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/105 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/105 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. CONCLUSIONS: Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/105 people/week) was a statistically independent predictor of mortality. TRIAL REGISTRATION NUMBER: CEIM 20/217.

Protocolo de intervención neuropsicológica en la cirugía del paciente despierto: experiencia de 3 años con tumores gliales / Neuropsychological management of the awake patient surgery: A protocol based on 3-year experience with glial tumors

INTRODUCCIÓN: Los tumores cerebrales gliales precisan habitualmente de un tratamiento neuroquirúrgico y se asocian con diversas alteraciones cognitivas, emocionales y comportamentales. El mapeo cerebral intraoperatorio es la técnica por excelencia utilizada para optimizar el equilibrio oncofuncional. La valoración e intervención desde la perspectiva neuropsicológica tiene gran relevancia en este tipo de procedimientos. Actualmente, se carece de una estructura protocolizada para la exploración y el seguimiento neuropsicológico que estos pacientes necesitan. MÉTODO: Se realiza un estudio descriptivo retrospectivo de 52 pacientes, todos ellos con diagnóstico de tumor glial, describiendo la estructura del protocolo desarrollado en nuestro centro. Se analizan los datos de la evaluación neuropsicológica, comparando el rendimiento inicial de los pacientes con su rendimiento posterior a la cirugía a corto y a largo plazo. RESULTADOS: Se describe nuestra experiencia en algunas las fases del protocolo, detallando las tareas que se han desarrollado para valorar a los pacientes dentro del quirófano. Los resultados de los datos de las evaluaciones neuropsicológicas objetivan déficits en el momento posterior a la cirugía que remiten en la valoración a largo plazo. CONCLUSIONES: Destacamos la necesidad de dar espacio y protocolizar en la asistencia hospitalaria los aspectos cognitivos y emocionales de los pacientes que sufren cualquier patología que conlleve daño cerebral adquirido. Este tipo de abordaje está orientado a aumentar la calidad de vida de los pacientes oncológicos estructurando y optimizando las tareas durante su intervención quirúrgica, pero también atendiendo a las dificultades neuropsicológicas que manifiesten

INTRODUCTION: Glial brain tumours usually require neurosurgical treatment and they are associated with cognitive, emotional and behavioural impairments. Awake intraoperative brain mapping is the gold standard technique used to optimize the onco-functional balance. Neuropsychological assessment and intervention have relevance in this type of procedures. Currently, there is a lack of protocolled structure for the neuropsychological intervention being able to satisfy patient needs. METHOD: A retrospective descriptive study of 52 patients was performed, all of them with a diagnosis of glial tumour. The structure of the protocol developed in our centre is reported, also data of neuropsychological evaluation, comparing baseline performance with both immediate posterior performance, and long term performance. RESULTS: We describe our experience in each step of the intervention, highlighting the development of eight neurocognitive protocols for intraoperative brain mapping. The results of the neuropsychological examination objectify deficits in the immediate after surgery assessment which are reduced in the long-term assessment. CONCLUSIONS: We emphasize the need of providing and structuring the cognitive and emotional aspects of patients suffering from any pathology that entails acquired brain damage in hospital environment. This type of approach is aimed at increasing the quality of life of cancer patients by structuring and optimizing tasks during their surgical intervention and attending to the neuropsychological difficulties they suffer

Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study.

BACKGROUND: Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria. METHODS: The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared. RESULTS: One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized. CONCLUSIONS: A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.

Neuropsychological management of the awake patient surgery: A protocol based on 3-year experience with glial tumors. / Protocolo de intervención neuropsicológica en la cirugía del paciente despierto: experiencia de 3 años con tumores gliales.

INTRODUCTION: Glial brain tumours usually require neurosurgical treatment and they are associated with cognitive, emotional and behavioural impairments. Awake intraoperative brain mapping is the gold standard technique used to optimize the onco-functional balance. Neuropsychological assessment and intervention have relevance in this type of procedures. Currently, there is a lack of protocolled structure for the neuropsychological intervention being able to satisfy patient needs. METHOD: A retrospective descriptive study of 52 patients was performed, all of them with a diagnosis of glial tumour. The structure of the protocol developed in our centre is reported, also data of neuropsychological evaluation, comparing baseline performance with both immediate posterior performance, and long term performance. RESULTS: We describe our experience in each step of the intervention, highlighting the development of eight neurocognitive protocols for intraoperative brain mapping. The results of the neuropsychological examination objectify deficits in the immediate after surgery assessment which are reduced in the long-term assessment. CONCLUSIONS: We emphasize the need of providing and structuring the cognitive and emotional aspects of patients suffering from any pathology that entails acquired brain damage in hospital environment. This type of approach is aimed at increasing the quality of life of cancer patients by structuring and optimizing tasks during their surgical intervention and attending to the neuropsychological difficulties they suffer.

Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians.

BACKGROUND: The number of hospitalized nonagenarians is increasing. Only a few studies have evaluated long-term predictors of survival in these patients. The aim of this study was to determine the 5-year outcome of a cohort of hospitalized nonagenarians, and to identify predictors of long-term survival. METHODS: In 124 consecutive medical hospitalized patients older than 89 years, and followed up during 5 years, the following variables were prospectively recorded: sociodemographic characteristics, main diagnoses, Charlson comorbidity index, Barthel index, Lawton-Brody test, Mini-Mental State Examination, Short Portable Mental Status Questionnaire of Pfeiffer, Mini Nutritional Assessment, albumin levels, and the 5-year survival. RESULTS: Out of the 124 patients, 109 died (87.9%) during the follow-up. The probability of being alive at 1, 3 and 5 years was 45%, 22% and 12%, respectively. A worse 5-year survival was significantly related to the diagnoses of pneumonia (p=0.037), heart failure (p=0.045), higher Charlson index (p=0.026), poorer functional status measured by the Barthel index (p=0.003), and the Lawton-Brody test (p=0.007), cognitive impairment measured by the Pfeiffer test (p=0.011), and lower levels of albumin (p=0.028). In the multivariate analysis, the Charlson index (p<0.001), and the Barthel index (p=0.003) were independently related to 5-year survival. These two variables were also 5-year survival prognostic factors in the subgroup of discharged patients. A prognostic index using these two variables was created: PI=(0.2 × Charlson index + 0.6 × Barthel index) × 0.92. CONCLUSIONS: In hospitalized nonagenarian patients, poor scores in the Barthel Index and a higher comorbidity evaluated by the Charlson index are independently related to 5-year survival.

A 69-year-old man with excessive sweating of the right hemithorax.

The pure autonomic failure is a rare entity, with only a few cases reported in the literature. The authors describe a case with compensatory excessive sweating of the right hemithorax as an initial manifestation of a pure autonomic failure, and the authors review the clinical characteristics of this disease. A 69-year-old man presented excessive sweating of the right hemithorax. Physical examination revealed orthostatic hypotension. No other neurological features were present. The autonomic study showed a low heart rate response to the Valsalva maneuver and reduced supine plasma norepinephrine levels. A pure autonomic failure was diagnosed. Treatment did not improve patient's symptoms. Anhidrosis with asymmetrical compensatory hyperhidrosis can be the only symptom of a pure autonomic failure. The authors highlight an unusual form of presentation of a rare disease, difficult to diagnose if it is not taken into consideration.