Deep brain stimulation in patients with long history of drug resistant epilepsy and poor functional status: Outcomes based on the different targets.

BACKGROUND: Deep brain stimulation (DBS) is a widely used surgical procedure for the treatment of patients with drug resistant epilepsy (DRE) and several anatomical target have been described. Indications for DBS includes patients with focal, partial seizure and those for which resective or disconnective surgery are contraindicated, such as involvement of eloquent cortex or significant comorbidities. Despite the SANTE trial has clearly indicated the efficacy of DBS of anterior nucleus of the thalamus (ANT), specific indications regarding the best anatomical target and outcome in patients with severe disability are lacking. Here we described our case series of patients underwent DBS of three different target including ANT, centromedian thalamic nucleus (CMN) and subthalamic nucleus (STN). METHOD: Six patients with DRE have been treated with DBS of ANT (n = 3), STN (n = 2) and CMN (n = 1). Outcome has been expressed as seizures frequency reduction and patients functional status after surgery with a follow-up of 5-11 years. RESULTS: Four out of six patients show no reduction of seizures frequency after DBS implant with one case of increasing atypical absence. Two cases, one ANT and one CMN, show a significant reduction of seizures frequency of 50-60%. No patients improve relative to functional outcome and one showed psychiatric symptoms worsening. CONCLUSIONS: For patients with DRE and severe functional disability, DBS may reduce seizure frequency in some cases, but it does not improve functional outcome.

Cognitive and linguistic outcomes after awake craniotomy in patients with high-grade gliomas.

BACKGROUND: Preservation of language and cognition is crucial in glioma surgery, as they are crucial aspects of daily life functioning. Several studies claimed that awake surgery in eloquent areas is demanded in low and high-grade gliomas. Cognitive and language outcome has been less investigated in high-grade gliomas compared to low-grade. METHOD: We analyzed the neuropsychological and neuro-oncological outcome of nineteen patients (from a cohort of forty patients) who underwent fully awake surgery for resection of malignant tumors located in eloquent areas. RESULTS: Post-surgery, linguistic functions were unchanged in 80 % of patients. Slight impairments in memory and executive functions were observed in about 50 % of patients. Survival rate at one year follow-up was 89 %. Results showed that awake procedure is safe, well tolerated and related with good linguistic outcome similar to low-grade gliomas. The majority of patients reported a good outcome in term of quality of life. CONCLUSIONS: Our results confirm that awake surgery is associated to good cognitive and linguistic clinical outcome also in malignant tumors.

Effectiveness of vagal nerve stimulation (VNS) in patients with drop-attacks and different epileptic syndromes.

PURPOSE: The effectiveness of VNS was evaluated in thirty-nine encephalopatic patients with drug-resistant epilepsy characterized by multiple seizures and drop attacks. Twenty-five patients were affected by severe epilepsy with multiple independent spike foci (SE-MISF) and fourteen patients by Lennox-Gastaut syndrome (LGS). METHOD: Changes in seizure frequency, cognition, adaptive behaviour and quality of life were assessed before and after VNS implant until three years. Outcome assessment for all seizure types included the number of seizures/month and the reduction in seizure frequency rate at each follow-up. Moreover, the effect of VNS on frequency, duration and intensity of drop attacks was separately addressed by a modification of McHugh scale. RESULTS: VNS produced a mean seizure rate reduction of 41% at six months, 50% at twelve months, and 54% at thirty-six months. After one year of stimulation, thirteen patients with SE-MISF (52%) and three patients with LGS (21%) showed a reduction above 50% in all seizures' frequency rate. As for drop attacks, eight patients (20%) gained a reduction above 50%, while seven patients (17%) showed a reduction only in intensity and duration. Cognitive level and adaptive behaviour were unchanged, while a better quality of life was reported in half out of the patients. CONCLUSIONS: VNS had a greater effect in reducing seizures frequency and drop attacks' intensity and duration in SE-MISF patients than LGS patients. An improved quality of life was observed also in those patients who only reduced the intensity and duration of drop attacks.

[Occupational medicine and communication: which role for print media?]. / Medicina del lavoro e comunicazione: l'uso dei media.

The diffusion of recent regulations on work safety has captured mass-media's interest on work accidents. The present work aims to highlight the role of print media in building a social representation of work safety, by performing a qualitative analysis of articles published between 2009 and 2010 in three of the main national newspapers. Results showed that print media are accurate in reporting news, but they do not serve as source of education in work safety's issues. Information is mainly focused around catastrophic events, with headlines inducing negative emotions. Very few articles contain a critical discussion of methods and operational proposals tested around the Country. A possible transformation of media's role in promoting work safety is discussed.

[Communication-based strategies to improve workers' health and safety: the role of the Responsible for Prevention and Protection Service (RSPP) and the Occupational Health Physician (OHP)]. / Le strategie relazionali ai fini della tutela dei lavoratori: il ruolo del Responsabile del Servizio Prevenzione e Protezione (RSPP) e del Medico Competente (MC).

Communication has a crucial role in enhancing workers' safety behaviours. In order to guarantee workers' safety and health, both the RSPP and the occupational health physician (OHP) need to be involved in frequent and personal relationships with other members in the organization. In the first part of the present work, the network of safety-related relationships within work environment is highlighted with respect to the specific regulations established by D.Lgs 81/2008. In the second part, the most effective behavioural approaches aimed to improve workers' safety behaviours are briefly presented. Particular emphasis is put on communication-based interventions which enhance leader-members exchanges. Incorporating these approaches into a comprehensive safety management system can be a key-tool to improve the effectiveness of both RSPP and OHP.

Cingulate epilepsy in a child with a low-grade glioma.

INTRODUCTION: Anterior cingulate epilepsy is a peculiar epileptic syndrome with a broad range of clinical manifestations, depending on the numerous projections of anterior cingulate into motor systems. Its diagnosis is often delayed, as seizures mostly occur during sleep and are typically misdiagnosed as parasomnias. Moreover, most focal anterior cingulate epilepsies are believed to be cryptogenic or idiopathic, even if there are some reports of anterior cingulate cortical dysplasia, while anterior cingulate neoplasms underlying epilepsy are rare. CASE REPORT: Here, we report a 30-month-old boy who developed, at the age of 20 months, cingulate epilepsy associated with a low-grade oligodendroglial tumor. It must outlined that the clinical presentation was characterized by very frequent and disabling seizures as the only symptom of the disease, while the results of several neuropsychological tests suggested intact intellectual and behavioral abilities. DISCUSSION AND CONCLUSION: Seizures disappeared completely after surgical removal of the lesion and neuropsychological child's performances remained completely normal. Long-term follow-up and observation are essential for evaluating the future clinical course.

Screening for developmental dysplasia of the hip: from theory to practice. Collaborative Group DDH Project.

OBJECTIVE: To evaluate an organizational model for neonatal population screening for developmental dysplasia of the hip. METHODS: In 4648 neonates born in six hospitals of the Lombardy region, screening for developmental dysplasia of the hip was done using the Ortolani-Barlow maneuver and ultrasonography. RESULTS: The frequency of positive results of clinical and ultrasound examinations carried out in the hospitals varied considerably as a result of difficulties in the Ortolani-Barlow test reproducibility and in the low sensitivity of the clinical examination when compared to ultrasonography. Neonatal screening results implied a large number of subjects with a IIa hip, according to Graf's system; as these subjects require follow-up, the cost of this type of screening is high. Ultrasound findings were normal at 69 days of life in 88% and 75% of subjects, respectively, with unilateral and bilateral type IIa hip. CONCLUSION: This study evaluated various organizational models for screening (for different time periods and for selected populations) in relation to the cost-benefit ratio and demonstrated the different problems that still impede identification of a correct screening model.

[Role of echo-color Doppler in the diagnosis of breast diseases. Personal experience]. / Ruolo dell'eco-color-Doppler nella diagnostica della mammella. Esperienza personale.

The role of color-Doppler US was investigated in the diagnosis of solid focal breast lesions. The results obtained with this method over the last two years were reviewed. Seventy-two patients with solid breast lesions were considered: conventional US scans of the nodules were performed first and color-Doppler scans followed, to depict vascularization. In benign focal lesions color-Doppler US never demonstrated more than a single vascular pole afferent to the lesion. In 92.5% of histologically malignant lesions, color-Doppler US easily demonstrated two or more feeding vessels. The analysis of our series confirmed the presence of a typical vascular pattern related to breast carcinoma which is easy to depict by means of color-Doppler US: this new technique is therefore of great value in the differentiation of benign from malignant breast masses, especially in the cases where conventional US and mammography alone failed to yield unquestionable and final results.

[Color-Doppler in the study of male sexual impotence]. / Il color-Doppler nello studio dell'impotenza sessuale maschile.

The authors report their experience with color-Doppler US in the study of 54 male patients with sexual impotence. The examination includes two distinct phases; in between, the erection-inducing drugs is injected directly in the cavernous bodies. During the basal phase, B-mode information relative to both morphology and structure of cavernous bodies is collected. After injecting the drug, systolic and end-diastolic velocities are evaluated as flowmetric indices, together with the resistive index; these variables are derived from cavernous arteries, at scheduled time--i.e., 5, 10 and 20 minutes after the injection. Moreover, the examined patients were divided into 4 groups according to their clinical response to the pharmacologic test. Color-Doppler US proved to be quite sensitive in the identification of the patients with a vascular alteration, both venous and arterial, underlying their erectile dysfunction; as a matter of fact, venous flights are easily depicted with the use of colors. The authors believe that color-Doppler could eventually become a major exam in the diagnosis of sexually impotent patients, thus allowing the marked reduction of such invasive diagnostic techniques as selective angiography of internal pudendum arteries and dynamic cavernosography, which are poorly tolerated by the patients.

[Portal hypertension of hepatic origin. A qualitative assessment by color and echo Doppler US]. / L'ipertensione portale di origine epatica. Valutazione qualitativa mediante color ed eco-Doppler.

One hundred and twenty-eight subjects were studied: 103 of them were affected with portal hypertension diagnosed both radiologically and clinically. Twenty-five healthy subjects were studied, as a control group, by means of combined real-time US and color Doppler. US parameters were evaluated, specific to chronic hepatopathy, together with the Doppler qualitative parameters relative to splanchnic vessels hemodynamics. Our results allowed a sort of noninvasive angiogram of the portal system to be obtained, which is to be of use for diagnosing portal hypertension, and for assessing its causes, risks, and consequences. This study was also aimed at suggesting an examination protocol for portal hypertension, employing real-time and color Doppler US, which any radiologist with enough experience in abdominal US could use. Color Doppler, although not strictly necessary to obtain good results, dramatically shortens execution times. Moreover, color Doppler allows the method to be more quickly learned.

[Color Doppler in the echographic evaluation of breast nodules]. / Il contributo del Color Doppler nella valutazione ecografica dei noduli mammari.

The authors report on their experience with color Doppler sonography in the diagnosis of solid breast masses. Twenty-two patients were examined; breast masses were studied with B-mode US first, and then with color Doppler US to evaluate eventual tumor vascularization. Color Doppler US demonstrated only one vascular pole in histologically confirmed benign masses. On the contrary, in 92.8% of histologically confirmed malignant masses, color Doppler easily depicted 2 or more groups of nutritional arteries. Color Doppler makes the diagnosis of malignant masses easier, thus allowing, in the author's opinion, a reduction in the number of biopsies of solid breast masses clinically/mammographically detected. The use of color Doppler US is therefore suggested: the technique is noninvasive, fast, and easy and its widespread use would translate into advantages for both the patient and the clinician.

[Doppler color in the echographic study of hyperplastic parathyroid glands]. / II contributo del color Doppler nello studio ecografico delle ghiandole paratiroidi iperplasiche.

The sonographic examination of hyperplastic parathyroid glands is a well-known and appreciated technique. However, its diagnostic contribution is still somehow inadequate, due to the difficult differential diagnosis of the various solid hyperechoic nodular structures in the neck and to the presence of frequently ectopic glands. The combined use of B-mode and color-Doppler US allows the vascular features of suspicious parathyroid nodules to be satisfactorily demonstrated. Higher sensitivity and specificity than conventional US are the main advantages of this technique. Still, further research is needed for B-mode color-Doppler US to actually replace fine needle biopsy in confirming the diagnosis.