Trait- and Frequency-Dependent Dysfunctional Habituation to Trigeminal Nociceptive Stimulation in Trigeminal Autonomic Cephalalgias

We investigated whether the stimulation frequency (SF), the pain phases, and different diagnoses of trigeminal autonomic cephalalgias (TACs) may influence the habituation to pain. We studied the habituation of the nociceptive blink reflex R2 responses at different SFs (.05, .1, .2, .3, .5, and 1?Hz), in 28 episodic cluster headache (ECH) patients, 16 during and 12 outside the bout; they were compared with 16 episodic paroxysmal hemicrania (EPH) during the bout and 21 healthy subjects. We delivered 26 electrical stimuli and subdivided stimuli 2 to 26 in 5 blocks of 5 responses for each SF. Habituation values for each SF were expressed as the percentages of the mean area value of second through fifth blocks with respect to the first one. A significant lower mean percentage decrease of the R2 area across all blocks was found at .2 to 1?Hz SF during ECH, outside of the ECH, and EPH compared with healthy subjects. We showed a common frequency-dependent deficit of habituation of trigeminal nociceptive responses at higher SFs in ECH and EPH patients, independently from the disease phase. This abnormal temporal pattern of pain processing may suggest a trait-dependent dysfunction of some underlying pain-related subcortical structures, rather than a state-dependent functional abnormality due to the recurrence of the headache attacks during the active period.

Transmitral Approach to Monopolar Radiofrequency Ablation of Inferior Papillary Muscle for Refractory Ischemic Ventricular Tachycardia

Despite the proven effectiveness of antiarrhythmic drugs and automated implantable cardioverter-defibrillators for ischemic ventricular arrhythmias, ablative procedures still play a major role. Herein, we report the cases of 2 patients who had malignant ventricular arrhythmias secondary to ischemic heart disease. The arrhythmias were treated intraoperatively by means of surgical ablation through a transmitral approach.Key words: Arrhythmias, cardiac/surgery; ventricular dysfunctionAlthough amiodarone and automated implantable cardioverter-defibrillator (AICD) therapy have proved effective for the treatment and prevention of malignant ischemic ventricular tachycardia, ablative procedures still play a major role.^1,2The site of origin of the left ventricular (LV) arrhythmia can greatly affect the complexity of surgical ablation. Whenever possible, intraoperative electrophysiologic mapping through a left ventriculotomy should precede ablation. Should the papillary muscles be the arrhythmogenic focus, their position inside the ventricle is an anatomic obstacle to endocardial resection, which can lead to severe mitral regurgitation.³We report 2 cases of ischemic heart disease in patients who developed malignant arrhythmias intraoperatively. These arrhythmias were treated by surgical ablation via a transmitral approach.     

Role of Growth Factors on Human Parathyroid Adenoma Cell Proliferation

Introduction

Primary hyperparathyroidism (pHPT) is caused by a single monoclonal adenoma in more than 80% of patients. Biomolecular mechanisms causing pHPT are still not completely known, even if a great amount of studies have been developed recently, mainly regarding angiogenesis and growth factors. Among the latter, insulin-like growth factor 1 (IGF-1), basic fibroblastic growth factor (bFGF), vascular endothelial growth factor (VEGF), and transforming growth factor beta 1 (TGF-β1) and their effects have been extensively evaluated in different kinds of endocrine disease.

Methods

Parathyroid cell cultures were prepared from six human adenomatous parathyroid glands that were surgically removed. After 7 days of culture, the cells were refed with DMEM supplemented with 2% FCS alone (control group), or containing hrTGFβ1, or hrIGF-I, or hrbFGF, or hrVEGF. Then, after 48-hour incubation, cell count was performed by a particle count and size analyzer, and prevalence of cell cycle was analyzed by using a flow cytometer.

Results

Cell count (×10000) in the control group was 3.73 ± 0.32. Low-dose TGF-β1 stimulation resulted in 5.25 ± 0.38 cells, and high-dose TGF-β1 stimulation resulted in 2.35 ± 0.37 cells. IGF-1 stimulation resulted in 5.4 ± 0.65 cells, bFGF stimulation in 5.68 ± 0.86 cells, and VEGF stimulation resulted in 6.03 ± 1.03 cells. Statistical analysis revealed significant differences in the control group compared with the growth factor-stimulated groups. Cytometry showed different results in the percentage of cells in S-phase, in particular 22.65 ± 4.98% of IGF-1-stimulated cells were found in S-phase compared with 7.55 ± 3.2% of control group cells (p < 0.0001).

Conclusions

Growth factors seem to play an important role in parathyroid adenoma cell proliferation; IGF-1, bFGF, VEGF, and low-dose TGF-β1 promote cell proliferation, whereas high-dose TGF-β1 inhibits these phenomena.     

Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.     

Rufinamide in children and adults with Lennox–Gastaut syndrome: First Italian multicenter experience

This is the first multicenter Italian experience with rufinamide as an adjunctive drug in children, adolescents and adults with Lennox–Gastaut syndrome.The patients were enrolled in a prospective, add-on, open-label treatment study from 11 Italian centers for children and adolescent epilepsy care. Forty-three patients (26 males, 17 females), aged between 4 and 34 years (mean 15.9 ± 7.3, median 15.0), were treated with rufinamide for a mean period of 12.3 months (range 3–21 months). Twenty patients were diagnosed as cryptogenic and 23 as symptomatic. Rufinamide was added to the baseline therapy at the starting dose of 10 mg/kg body weight, evenly divided in two daily doses and then increased by 10 mg/kg approximately every 3 days up to a maximum of 1000 mg/day in children aged ≥4 years with a body weight less than 30 kg. In patients more than 30 kg body weight, rufinamide could be titrated up to 3200 mg/day.After a mean follow-up period of 12.3 months (range 3–21 months), the final mean dose of rufinamide was 33.5 mg/kg/24 h (range 11.5–60) if combined to valproic acid, and of 54.5 mg/kg/24 h (range 21.8–85.6) without valproic acid. The response rate (≥50% decrease in countable seizures) was 60.5% (26 of 45 patients) in total; 51.1% experienced a 50–99% reduction in seizure frequency and complete seizure control was achieved in the last 4 weeks follow-up by 9.3% of patients. Two patients (4.7%) had a 25–50% seizure reduction, while seizure frequency remained unchanged in 13 (30.2%) and increased in 2 (4.7%). Reliable data for atypical absence seizures and myoclonic seizures were not available, as these are usually impossible to count.Ten patients (23.2%) reported adverse side effects, while taking rufinamide. They were generally mild and transient and most frequently included vomiting, drowsiness, irritalibility and loss of appetite.In conclusion, rufinamide as an adjunctive therapy reduced the number of drop attacks and major motor seizures in about 60% of patients with Lennox–Gastaut syndrome and produced only mild or moderate adverse side effects.     

Primary hypothalamic lymphoma in a patient with systemic lupus erythematosus: case report and review of the literature

A 67-year-old female was admitted to our department with difficulty in speech, disorientation, memory loss and seizures. Blood laboratory tests revealed diabetes insipidus. This patient had been treated with steroids for systemic lupus erythematosus (SLE) for 30 years. Due to this treatment neurological symptoms had been understated causing a long delay in performing ulterior researches. A brain MRI revealed a mass lesion in the hypothalamic area. A biopsy was performed and histopathological diagnosis was malignant large B cell lymphoma. Subsequently, she received methotrexate therapy but died of pneumonia during the second cycle. Primary central nervous system lymphoma in association with SLE is a rare occurrence but it should be considered in the diagnostic process when neurological symptoms occur. A brain MRI must be performed and corticosteroids should be interrupted. A biopsy of the cerebral mass lesion permits diagnosis and appropriate therapy may be administered.     

Circumcision is not mandatory in penile surgery

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To assess the outcome of not circumcising patients having surgery to correct a congenital or acquired curvature, through a subcoronal approach.

PATIENTS AND METHODS

In a series of 251 consecutive patients (mean age 46 years, range 17–74) that had their penis straightened by either a Lue (86), or a Nesbit procedure (162) or a combination of both (three) between 2000 and 2008, a subcoronal circumferential incision was used for the degloving in 241. Among the 183 patients who had not been previously circumcised, 22 presented with a tight foreskin and were offered a circumcision; six of them refused to be circumcised. Of the remaining 161 patients, 115, including two who had previous penile surgery, opted not to be circumcised.

RESULTS

After a median (range) follow‐up of 5.5 (1–50) months, secondary circumcision was performed in three of the six patients with a tight foreskin, in one of the 113 (0.8%) with a normal retractable foreskin and in one of the two who had had previous penile surgery and had a normal foreskin.

CONCLUSIONS

Circumcision should not be considered as a routine part of penile surgery unless a significant phimosis is present or revisional surgery is contemplated.     

Lymph node retrieval and examination during the implementation of extended lymph node dissection for gastric cancer in a non-specialized western institution

The optimal degree of lymph node dissection for gastric cancer is still matter of debate. Particularly, there are serious doubts about the reproducibility of extended lymph node dissection in western surgical units, and no studies to date have investigated factors influencing lymph node retrieval and examination during the learning curve. Univariate and multivariate retrospective analysis of 21 variables were carried out on a prospective series of 313 consecutive resections for gastric cancer performed by ten different surgeons, with lymph node retrieval and analysis performed by ten different pathologists. Endpoints were number of examined lymph nodes per patient, number of cases with inadequate nodal staging (<15 examined lymph nodes) and lymph node ratio (calculated as the absolute ratio between the number of metastatic and the number of examined lymph nodes). The number of examined lymph nodes per patient (mean ± SD 28.3 ± 14.1, median 26, range 2–78) was independently influenced by age, pN status, the type of gastric resection, the degree of lymph node dissection and single pathologist. There were 47 cases (15.0%) with incomplete nodal staging that was independently determined by the degree of lymph node dissection and by the pathologist. Lymph node ratio was independently influenced by the number of metastatic lymph nodes, the disease stage and by the histological subtype of the tumor. The role of an experienced or dedicated pathologist should not be underevaluated in western series when dealing with lymph node retrieval and examination. Lymph node ratio appeared not to be significantly influenced by the number of examined lymph nodes, being independently influenced only by the number of metastatic lymph nodes, the disease stage and by the histological subtype of the tumor. It could be therefore tested as a prognostic factor limiting the stage-migration phenomenon induced by extended lymph node dissection.