Anatomical identification of active contacts in subthalamic deep brain stimulation

BACKGROUND: Subthalamic Deep Brain Stimulation is a valid surgical procedure for the treatment of idiopathic PD, although its precise mechanism of action is still unclear; moreover, there are no conclusive data about the functional anatomy of the human subthalamic region. Identifying the location of active contacts for StnDBS can yield interesting insights on the mechanisms of action of DBS and the different role played by the anatomical structures of the subthalamic region. METHODS: Twenty-five patients operated on for bilateral StnDBS were considered. During the surgical procedure, a complete intraoperative neurophysiological study was obtained by means of semimicrorecordings and stimulations. After surgery, an MRI study confirmed the position of the electrodes; MR images were subsequently superimposed onto a stereotactic atlas by using a dedicated workstation. The coordinates relative to the tip of the electrodes and active contacts were then calculated. RESULTS: Most of the electrode tips are located inside the subthalamus or immediately ventrally to it. Of the active contacts used for chronic stimulation, 96.5% are located in a well-defined anatomical region, which includes subthalamus, zona incerta, and FF. CONCLUSIONS: Our findings seem to suggest that other structures beyond the subthalamus itself play a clinical role in symptoms control after DBS for PD.     

The Bolognese surgeon Giuseppe Ruggi: how and why the aseptic surgery was introduced in Bologna in the middle half of the XIX century

Background

The first reliable statistic data about perioperatory mortality were published in 1841 by the French Joseph-Francois Malgaigne (1806–1863): he referred to a mean mortality of 60% for amputations and this bad result was to be attributed mainly to hospital acquired diseases. The idea of “hospital acquired disease” although vague, included five infective nosologic entities, which at that time were diagnosed more frequently: erysipelas, tetan, pyemia, septicemia, and gangrene. Nonetheless, the suppuration with pus production was considered from most of the surgeons and doctors of that time as a necessary and unavoidable step in the process of wound healing. During the end of the eighteenth century, hospitals of the main European cities were transforming into aggregations of several wards, where the high concentration of patients created poor sanitary conditions and a consistent increase of perioperatory mortality. In 1865, Lister applied his first antiseptic dressing on the surface of an exposed fracture. These experimental attempts lead to an effective reduction of wound infections respect to the dressing with strings used previously.

Discussion

Lister's innovations in the field of wound treatment were based on two brand new concepts: germs causing rot were ubiquitarious and the wound infection was not a normal step in the process of wound healing. The concept of antisepsis was hardly accepted in the European surgical world: “Of all countries, Italy is the most indifferent and uninterested in experimenting this method, which has been so favorably judged from the greatest surgical societies in Germany”. This quotation from the young surgeon Giuseppe Ruggi (1844–1925) from Bologna comes from his article where he presented his first experiences on aseptic medications started the previous year in the Surgical Department of Maggiore Hospital in Bologna. In his report, Ruggi described the adopted technique and suggested that the medication should be extended to all the surgical patients of the hospital:“… this is needed to totally remove from the hospital all those elements of infection which grow in the wounds dressed with the old method”. The experimentation of this new dressing for the few treated cases was rigorous and concerned both the sterilization of surgical tools with the fenic acid (5%) and the shaving of the skin. Ruggi also observed that there was no correlation between the seriousness of the wound and its extension or way of healing: when “simple” cases that “should heal without complication” showed fever he often realized that “it was often due to a medication performed without following the rules for an accurate disinfection and dressing”. Ruggi thought that the fever was connected to “reabsorption of pyrogenic substances, which can be removed cleaning and disinfecting the wound” in cases of wounds not accurately dressed and rarely medicated. Frequent postoperative medications of the wound were able to eliminate the fever within 2 h. Ruggi's attitude toward the fine reasoning lead him to introduce the concept of immunodeficiency related to physical deterioration: “… patients treated for surgical disease may sometimes suffer from complications of medical conditions, which initially escape the most accurate investigations… The surgical operation could, in some cases, hold the balance of power”.

Conclusions

The obtained results, published in 1879, appear extremely interesting. As he wrote in 1898, for the presentation of his case record of more than 1000 laparotomies, he had started “… operating as a young surgeon without any tutor, helped only by his mind and what he could deduce from publications existing at the moment …”.     

Vitamin D insufficiency and subclinical atherosclerosis in non-diabetic males living with HIV

Introduction

Vitamin D insufficiency (VDI) has been associated with increased cardiovascular risk in the non-HIV population. This study evaluates the relationship among serum 25-hydroxyvitamin D [25(OH)D] levels, cardiovascular risk factors, adipokines, antiviral therapy (ART) and subclinical atherosclerosis in HIV-infected males.

Methods

A cross-sectional study in ambulatory care was made in non-diabetic patients living with HIV. VDI was defined as 25(OH)D serum levels <75 nmol/L. Fasting lipids, glucose, inflammatory markers (tumour necrosis factor-α, interleukin-6, high-sensitivity C-reactive protein) and endothelial markers (plasminogen activator inhibitor-1, or PAI-I) were measured. The common carotid artery intima-media thickness (C-IMT) was determined. A multivariate logistic regression analysis was made to identify factors associated with the presence of VDI, while multivariate linear regression analysis was used to identify factors associated with common C-IMT.

Results

Eighty-nine patients were included (age 42±8 years), 18.9% were in CDC (US Centers for Disease Control and Prevention) stage C and 75 were on ART. VDI was associated with ART exposure, sedentary lifestyle, higher triglycerides levels and PAI-I. In univariate analysis, VDI was associated with greater common C-IMT. The multivariate linear regression model, adjusted by confounding factors, revealed an independent association between common C-IMT and patient age, time of exposure to protease inhibitors (PIs) and impaired fasting glucose (IFG). In contrast, there were no independent associations between common C-IMT and VDI or inflammatory and endothelial markers.

Conclusions

VDI was not independently associated with subclinical atherosclerosis in non-diabetic males living with HIV. Older age, a longer exposure to PIs, and IFG were independent factors associated with common C-IMT in this population.     

Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial

Background

Several studies have demonstrated skills transfer after virtual reality (VR) simulation training in laparoscopic surgery. However, the impact of VR simulation training on transfer of skills related to laparoscopic colectomy remains not investigated. The present study aimed at determining the impact of VR simulation warm-up on performance during laparoscopic colectomy in the porcine model.

Methods

Fourteen residents naive to laparoscopic colectomy as surgeons were randomly assigned in block to two groups. Seven trainees completed a 2-h VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a sigmoid colectomy with anastomosis on a pig. All operations were video recorded. Two board-certified expert colorectal surgeons independently assessed performance during the colectomy on the swine. Examiners were blinded to group assignment. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. The primary outcome was the generic and specific skills score values.

Results

Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig regarding general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5–18) for the control group and 20.1 (16.5–22) for the study group (p = 0.002). The specific skills average score for the control group was 20.2 (19–21.5) and 24.2 (21–27.5) for the study group (p = 0.001). There was acceptable concordance (Kendall’s W) regarding the video assessment of generic (W = 0.78) and specific skills (W = 0.84) between the two examiners.

Conclusions

A single short-duration VR simulator practice positively impacted surgeons’ generic and specific skills performance required to accomplish laparoscopic colectomy in the swine model.     

Two Stages Conversion of Failed Laparoscopic Adjustable Gastric Banding to Laparoscopic Roux-En-Y Gastric Bypass. A Study of One Hundred Patients

Introduction

Conversion to laparoscopic gastric bypass (LRYGB) appears to be the treatment of choice after failed LAGB. To reduce the risk of postoperative complications, some surgeons routinely adopt a two-stage strategy. The purpose of this study was to analyze our institution’s experience with the two-stage procedure for LAGB conversion to LRYGB

Materials and Methods

The bariatric database of our institution was reviewed to identify patients who had undergone conversion of LAGB to LRYGB from November 2007 to June 2012.

Results

One hundred patients were included. Of these, 62 (62 %) required conversion to LRYGB for inadequate weight loss or weight regain and 38 for band-related complications. All the procedures were performed in two stages and laparoscopically. The average time between band removal and LRYGB was 17.3 months. The mean follow-up after LRYGB was 31?±?18.7 months. The mean BMI prior to LRYGB conversion was 45.3?±?5.2. Early complications occurred in 15 patients (15 %), while late complications occurred in only 3 patients (3 %). The average %EWL at 24 months and 48 months after conversion was 70.1 and 69.4 %, respectively.

Conclusion

Although a two-stage conversion strategy increases the number of operations and hospital stay without decreasing the rate of early complications compared to one-stage conversion; it has shown to be associated with low rates of GJA stenosis and excellent %EWL.     

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

Context

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

Cylindroma of the breast of skin adnexal type: a study of 4 cases

Four cases of solitary cylindroma of the breast of skin adnexal type are described. The tumors were morphologically and immunophenotypically identical to their dermal counterparts. They arose in close proximity to the nipple, such as the retroareolar area of the breast and in intimate association with the lactiferous ducts, suggesting an origin from the latter structures. One case occurred in a woman with hereditary multiple cylindromatosis (Brooke-Spiegler syndrome). This is the second reported case of this hereditary syndrome with extracutaneous manifestations and the first case in which the breast is involved.     

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

Background: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. Methods: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. Results: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 ± 12 years, with mean BMI 47 ± 9 kg/m². 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 ±16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 ± 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). Conclusions: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.     

Dynamic contrast-enhanced ultrasound with carbon dioxide microbubbles as adjunct to arteriography of liver tumors

Purpose The goal of the study is to evaluate utility of contrast enhanced ultrasound (US) with carbon dioxide microbubbles in evaluation of hepatic lesions.Methods Twenty eight patients with single or multiple t hepatic lesions (11 hepatocellular carcinoma, 8 hemangiomas, 5 metastases, 1 adenoma, 1 focal nodular hyperplasia, 2 regenerative nodules) were examined. US exam was performed during intraarterial injection of 10 ml of CO₂ through the same catheter employed for liver arteriography. The US exam was videotaped in its salient phases. Characteristics of enhancement were evaluated and correlated with histological findings or patient follow up.Results Sonographic angiography clearly demonstrated vascularization of the lesions. Hepatocellular carcinoma, hemangioma, metastases, focal nodular hyperplasia, and regenerative nodules had very characteristic patterns. The injection of CO₂ allowed detection of small additional nodules.Conclusion Sonographic angiography can improve characterization and staging of hepatic tumors. Low cost and the simplicity of the technique should encourage further experimentation.     

Investigation of the electrophysiological correlates of negative BOLD response during intermittent photic stimulation: An EEG‐fMRI study

Although the occurrence of concomitant positive BOLD responses (PBRs) and negative BOLD responses (NBRs) to visual stimuli is increasingly investigated in neuroscience, it still lacks a definite explanation. Multimodal imaging represents a powerful tool to study the determinants of negative BOLD responses: the integration of functional Magnetic Resonance Imaging (fMRI) and electroencephalographic (EEG) recordings is especially useful, since it can give information on the neurovascular coupling underlying this complex phenomenon. In the present study, the brain response to intermittent photic stimulation (IPS) was investigated in a group of healthy subjects using simultaneous EEG‐fMRI, with the main objective to study the electrophysiological mechanisms associated with the intense NBRs elicited by IPS in extra‐striate visual cortex. The EEG analysis showed that IPS induced a desynchronization of the basal rhythm, followed by the instauration of a novel rhythm driven by the visual stimulation. The most interesting results emerged from the EEG‐informed fMRI analysis, which suggested a relationship between the neuronal rhythms at 10 and 12 Hz and the BOLD dynamics in extra‐striate visual cortex. These findings support the hypothesis that NBRs to visual stimuli may be neuronal in origin rather than reflecting pure vascular phenomena. Hum Brain Mapp 37:2247–2262, 2016. © 2016 Wiley Periodicals, Inc.