Dexamethasone on absent end-diastolic flow in umbilical artery,in growth restricted fetuses from early-onset preeclamptic pregnancies and the perinatal outcome

BackgroundAbsent end-diastolic flow (AEDF) in the umbilical artery (UA) worsens the already poor prognosis of growth-restricted fetuses (GRFs) in pregnancies complicated by early-onset preeclampsia with severe features (ESP).MethodWe assessed the correlation between the effect of maternal dexamethasone (Dex) on AEDF in the UA and perinatal outcomes, in 59 GRFs from EPS-complicated pregnancies. The maternal outcome was also evaluated.ResultsThe mean maternal age at inclusion was 22.4 ± 5.9 years. Dex transiently restored EDF in the UA in 38 (64.4%) cases (trAEDF group), but in 21 (35.6%) patients, the flow was persistently absent (prAEDF group). The effect lasted up to the 4th day.The gestational age at diagnosis, number of days from admission until delivery, and fetal weight were significantly lower in the prAEDF group than in the trAEDF group (p < .05). The same group had a significantly increased rate of fetal proximal deterioration, low APGAR scores, neonatal hypoxia, assisted ventilation, mild intraventricular haemorrhage (I/II), and respiratory distress syndrome, as well as maternal deterioration, especially in cases of resistant hypertension (p < .05). Although the rates of fetal acidemia and perinatal mortality in the prAEDF group were respectively three times and two times higher, the differences were not significant (p > .05).ConclusionsThe Dex no-effect on UA Doppler in GRFs with AEDF in the UA, in EPS-complicated pregnancies, can be a useful marker for a higher risk of proximal fetal deterioration, poor state at delivery, neonatal hypoxic complications, and worsening maternal condition, but not for perinatal mortality. The findings also highlight the alarmingly younger age of patients with EPS. Finally, all these pregnancies should be monitored in a complex multidisciplinary manner in tertiary referral units.

Key message

• The effect of dexamethasone on absent end-diastolic flow in the umbilical artery in growth-restricted fetuses from pregnancies complicated by early-onset preeclampsia with severe features can be a useful prognostic factor for perinatal outcomes.

     

Intravenous amiodarone in acute anterior myocardial infarction: A controlled study

Summary A randomized, single-blind controlled study intended to assess the potential benefits of intravenous amiodarone in anterior myocardial infarction is presented. Three hundred nineteen patients entered the study, 159 received amiodarone infusion, and 160 received glucose-insulinpotassium (GIK) infusion. Basal characteristics were similar in the two experimental groups, who were randomized on a consecutive basis. Exclusion criteria were shock or pulmonary edema, hypotension, inferoposterior infarction, bradycardia, antrioventricular block, severe diabetes, and other major diseases.Patients aged 27 to 70 years, with a Q-wave anterior infarction, initiated 12–40 hours earlier at the time of admission, entered the trial. Other entry criteria were heart rate higher than 80 beats/min and systolic blood pressure higher than 100 mmHg. Amiodarone was administered in saline infusion 10–20 mg/kg, within 4 to 10 hours, through a central vein. GIK infusion consisted of 150–300 g of glucose, 25–50 IU of insulin, and 80–120 mEq of KCl in 1000 cc of water at a rate of 1.5–2.0 ml/g/hour. Both groups received digitalis, nitrates, sedatives, and diuretics as needed.Although individually the major endpoints of death, reinfarction, and sustained supraventricular and ventricular arrhythmias did not differ significantly, each was less in the amiodarone group than in the control, and the sum of all adverse events was significantly lower for the amiodarone patients (p<001). Heart failure and conduction disturbances were not different in the two groups.This study shows that amiodarone, with its vasodilating and antiarrhythmic properties, may be beneficial in acute anterior infarction, but further studies on larger populations will be necessary in order to show a reduction of mortality rate.     

Observation of others’ actions during limb immobilization prevents the subsequent decay of motor performance

There is rich clinical evidence that observing normally executed actions promotes the recovery of the corresponding action execution in patients with motor deficits. In this study, we assessed the ability of action observation to prevent the decay of healthy individuals’ motor abilities following upper-limb immobilization. To this end, upper-limb kinematics was recorded in healthy participants while they performed three reach-to-grasp movements before immobilization and the same movements after 16 h of immobilization. The participants were subdivided into two groups; the experimental group observed, during the immobilization, the same reach-to-grasp movements they had performed before immobilization, whereas the control group observed natural scenarios. After bandage removal, motor impairment in performing reach-to-grasp movements was milder in the experimental group. These findings support the hypothesis that action observation, via the mirror mechanism, plays a protective role against the decline of motor performance induced by limb nonuse. From this perspective, action observation therapy is a promising tool for anticipating rehabilitation onset in clinical conditions involving limb nonuse, thus reducing the burden of further rehabilitation.

There is rich clinical evidence that observing normally executed actions promotes the recovery of the corresponding action execution in patients with motor deficits. This procedure, which is based on the activation of the motor system via the mirror mechanism (1, 2), is called action observation treatment (AOT) (3, 4). The effectiveness of AOT in motor recovery has been demonstrated in several clinical conditions, including stroke (5–7), Parkinson''s disease (8–10), multiple sclerosis (11), and cerebral palsy (12–16), as well as in patients with orthopedic trauma and postsurgical patients (17–19).In recent decades, researchers have advanced covert motor approaches based on action observation other than AOT. Such approaches include mirror therapy (20, 21), which improves the symptoms resulting from absent or altered feedback from the affected side of the body [e.g., phantom pain in arm amputees (22, 23)] and may also enhance motor function in poststroke patients (24–26). More recently, noninvasive brain stimulation techniques, such as transcranial magnetic stimulation, transcranial direct current stimulation, and peripheral electrical stimulation, have been used to enhance motor recovery in neurological (27–29) and orthopedic patients (30). When tested in combination with interventions based on action observation, these approaches exhibited the ability to enhance the magnitude of treatment effects (31, 32).In some of the abovementioned clinical conditions, especially those involving orthopedic trauma or affecting the peripheral nervous system, the patient may experience a period of limb nonuse. It has been demonstrated that limb nonuse (or disuse) induces a reduction in the size and excitability of the cortical representation of the immobilized limb, gradually leading to maladaptive plasticity changes and the appearance of motor alterations (33–35), which can interfere with the rehabilitative outcome. In this context, action observation is an effective treatment alternative when physical therapy is not applicable. The aim of the present study is to determine whether administering AOT during the immobilization period can limit the progressive impoverishment of motor performance—an effect researchers have yet to be establish.To this end, a short-term immobilization (STI) was administered to healthy volunteers. This procedure is commonly used to model the neurophysiological changes leading to motor impairments in injured people (reviews are in refs. 36 and 37) because it minimizes the impact of confounding variables (e.g., immobilization duration, cause of immobilization, associated pain, potential comorbidities) and consequently, isolates the hypoactivity-induced effects on neurophysiological processes. Moreover, the use of healthy volunteers enables a within-subjects comparison between pre- and postimmobilization performance, whereas the use of clinical populations makes the same procedure virtually impossible due to the sudden nature of the injury.The participants were subdivided into two groups: those receiving AOT and those receiving control stimulations. In both groups, the upper-limb kinematics of goal-directed movements was tested before and after the immobilization. We evaluated whether the motor performance of subjects who underwent AOT was better preserved after the immobilization compared with that of the control (CTRL) group, and we determined which aspects of movement organization were mostly affected by AOT.The present study’s results could lead to the use of AOT during immobilization in a spectrum of clinical conditions in which the patient''s movement is transiently impeded, thus favoring an early treatment onset and potentially limiting the extent of motor deficits to be later rehabilitated.     

Immunohistochemical expression and localization of somatostatin receptor subtypes in androgen ablated prostate cancer

Objective

The aim was to examine the expression and localization of the five somatostatin receptors (termed SSTR1 to 5) in radical prostatectomies (RPs) from patients with prostatic adenocarcinoma (PCa) under complete androgen ablation (CAA) before operation.

Material

The five SSTRs were evaluated in the epithelial, smooth muscle and endothelial cells of normal-looking epithelium (Nep), high-grade prostatic intraepithelial neoplasia (HGPIN) and PCa in 20 RPs with clinically detected PCa from patients under CAA. Twenty RPs with clinically detected PCa from hormonally untreated patients were used as control group.

Results

Concerning the secretory cells (i) Membrane staining was seen for SSTR3 and SSTR4; the mean percentages of positive cells, higher in SSTR3 than in SSTR4, decreased sharply in HGPIN and PCa compared with Nep; the mean percentages in the androgen ablated group were 30% to 90% lower than in the untreated; (ii) Cytoplasmic staining was seen for all five SSTRs; the mean percentages of positive cells in Nep, HGPIN and PCa of the untreated group were similar, and in general as high as 80% or more; in the treated group, the Nep values were similar to those in the untreated, whereas the values in HGPIN and PCa were lower for SSTR1, three and five, with a decrease of 30% for SSTR1; (iii) Nuclear staining was seen with SSTR4 and SSTR5, the mean percentages for the former being much lower than for the latter; treatment affected both HGPIN and PCa, whose proportions of stained cells were 30% to 55% lower than in the untreated group. Cytoplasmic staining in the basal cells was seen for all five SSTRs, both in Nep and HGPIN. The values in the treated group were lower than in the other, the difference between the two group being in general comprised between 10% and 40%. Treatment did not affect SSTR staining in the smooth muscle and endothelial cells.

Conclusions

The present study expands our knowledge on the expression and localization of the five SSTRs in the prostate following CAA.     

Complex epileptic palilalia: A case report

Palilalia is a kind of motor perseveration involving speech, consisting in the continuous repetition of words or phrases, or both. Rarely it occurs in seizure disorders as ictal or post-ictal manifestation. We report a case of epileptic palilalia in a 71-year-old patient with a previous history of intracerebral haemorrhage in the left frontal region, characterized by the continuous repetition of the same speech sequence for few minutes. EEG recordings during NREM sleep and wakefulness showed recurrent and prolonged focal subclinical epileptiform paroxysms in the left mesial frontal region. Our case confirms the role of the left frontal lobe, reliably of the supplementary motor area (SMA), as neuroanatomic origin of ictal palilalia.     

Asymptomatic carotid plaque rupture with unexpected thrombosis over a non-canonical vulnerable lesion

Objective

Several studies have demonstrated that carotid plaque rupture and thrombosis represent the most important factors correlated with the onset of acute cerebrovascular symptoms. Nevertheless, ruptured thrombotic plaques have been described also in asymptomatic patients. What still needs to be clarified is why a plaque rupture leads either to an acute ischemic syndrome or, in a minor group of patients, remains asymptomatic. The purpose of this study was to systematically compare the histologic features of thrombotic plaques both in asymptomatic and symptomatic patients in order to identify specific findings that could explain the peculiar clinical behavior that characterizes each of the clinical settings.

Methods

A total of 157 thrombotic plaques from 60 asymptomatic patients and 97 with major stroke who consecutively underwent CEA were serially sectioned and studied by histology.

Results

A minute cap disruption very frequently characterizes thrombotic plaques of asymptomatic patients and it was always smaller than large ulcers observed in thrombotic symptomatic plaques (651 ± 687 μm vs. 4150 ± 3526, p = 0.001). In asymptomatics this typical feature was associated with fewer inflammatory cells (20.1 ± 8.8 vs. 33.9 ± 26.1 cells × hpf, p = 0.001), smaller lipidic–necrotic core (33.9% ± 2.9% vs. 42.0% ± 2.4%; p = 0.04) and larger calcification (16.2 ± 12.8% vs. 8.1 ± 12.2%, p = 0.02). Symptomatic patients with thrombotic plaques showed higher incidence of metabolic syndrome (p = 0.002) and moderate-high Framingham risk scores (p = 0.001) comparing to asymptomatic individuals.

Conclusion

The transformation from a stable to a vulnerable plaque is a gradual process in the natural history of the disease and plaque rupture is an event not necessarily occurring at a late phase but also at earlier one. In this case, the rupture will be most likely smaller and clinically asymptomatic.