Deepbrain stimulation of the nucleus accumbens in obsessive compulsive disorder: clinical, surgical and electrophysiological considerations in two consecutive patients

Abstract Obsessive compulsive disorder is a highly disabling pathological condition which in the most severe and drug-resistant form can severely impair social, cognitive and interpersonal functioning. Deep-brain stimulation has been demonstrated to be an effective and safe interventional procedure in such refractory forms in selected cases. We here report the first Italian experience in the treatment of this pathology by means of nucleus accumbens stimulation, pointing out to some technical data which could be of help in localization of the target

An olfactory reference syndrome successfully treated by aripiprazole augmentation of antidepressant therapy

Abstract: Objective: To describe a case of a 65-year-old woman with persistent olfactory hallucination and delusional self-reference, successfully treated by aripiprazole augmentation of antidepressant therapy. Background: Olfactory reference syndrome is a nosologic entity, which has been assimilated to various Diagnostic and Statistical Manual of Mental Disorder-IV-text revision codified diseases and several pharmacologic treatments have been proposed without a constant clinical response. Method: Psychiatric, neurologic, neuropsychologic, imaging, and electroencephalogram data are reported. Results: The patient showed a significant improvement with aripiprazole. Conclusions: We propose a pathophysiologic model of olfactory reference syndrome to explain the good response of our patient to aripiprazole. We hypothesize a disruption in the top-down regulation of the orbitofrontal cortex on the primary olfactory cortex and the olfactory bulb at the basis of the illness. Aripiprazole acting as a partial agonist of dopamine D2 receptors in the olfactory bulb compensates for the lack of modulation in this site, restoring the correct processing of olfactory information

Repetitive TMS on left cerebellum affects impulsivity in borderline personality disorder: A pilot study

The borderline personality disorder (BPD) is characterized by a severe pattern of instability in emotional regulation, interpersonal relationships, identity and impulse control. These functions are related to the prefrontal cortex (PFC), and since PFC shows arichanatomicalconnectivitywiththecerebellum,thefunctionalityofthecerebellar-PFC axis may impact on BPD. In this study, we investigated the potential involvement of cerebello-thalamo-cortical connections in impulsive reactions through a pre/post stimulation design. BPD patients (n = 8) and healthy controls (HC; n = 9) performed an Affective Go/No-Go task (AGN) assessing information processing biases for positive and negative stimuli before and after repetitive transcranial magnetic stimulation (rTMS; 1 Hz/10 min, 80% resting motor threshold (RMT) over the left lateral cerebellum. The AGN task consisted of four blocks requiring associative capacities of increasing complexity. BPD patients performed significantly worse than the HC, especially when cognitivedemandswerehigh(thirdandfourthblock),buttheirperformanceapproached that of HC after rTMS (rTMS was almost ineffective in HC). The more evident effect of rTMS in complex associative tasks might have occurred since the cerebellum is deeply involved in integration and coordination of different stimuli. We hypothesize that in BPD patients, cerebello-thalamo-cortical communication is altered, resulting in emotional dysregulation and disturbed impulse control. The rTMS over the left cerebellum might have interfered with existing functional connections exerting a facilitating effect on PFC contro

Survival after active surveillance versus upfront surgery for incidental small pancreatic neuroendocrine tumours

Background The safety of observing small non-functioning pancreatic neuroendocrine tumours (NF-Pan-NETs) remains under debate. Methods This was a multicentre retrospective study of patients with small incidental NF-Pan-NETs. Survival of patients who underwent upfront surgery versus active surveillance was compared. The risk of death was matched with that in the healthy population. The excess hazard rate and probability of a normal lifespan (NLP) were calculated. Propensity score matching (PSM) with a 1 : 1 ratio was used to minimize the risk of selection bias. Results Some 222 patients (43.7 per cent) underwent upfront surgery and 285 (56.3 per cent) were observed. The excess hazard rate for the entire cohort was quantifiable as 0.04 (95 per cent c.i. 0 to 0.08) deaths per 1000 persons per year, and the NLP was 99.7 per cent. Patients in the active surveillance group were older (median age 65 versus 58 years; P < 0.001), and more often had co-morbidity (45.3 versus 24.8 per cent; P = 0.001), and smaller tumours (median 12 versus 13 mm; P < 0.001), less frequently located in the pancreatic body-tail (59.5 versus 69.6 per cent; P = 0.008, 59.3 versus 73.9 per cent; P = 0.001). Median follow-up was longer for patients who underwent upfront surgery (5.6 versus 2.7 years; P < 0.001). After PSM, 118 patients per group were included. The excess hazard rates were 0.2 and 0.9 deaths per 1000 persons per year (P = 0.020) for patients in the active surveillance and upfront surgery groups respectively. Corresponding NLPs were 99.9 and 99.5 per cent respectively (P = 0.011). Conclusion Active surveillance of small incidental NF-Pan-NETs is a reasonable alternative to resection.To aim was to evaluate whether a watchful strategy increased mortality risk compared with surgery. The study included 507 patients with small non-functioning pancreatic neuroendocrine tumours (NF-Pan-NETs). Some 222 patients (43.7 per cent) underwent upfront surgery and 285 (56.3 per cent) had active surveillance. Active surveillance for small incidental NF-Pan-NETs can be considered safe because it did not increase the background risk of death.Lay summary Neuroendocrine tumours are rare tumours which are most often found in the lungs, gastrointestinal tract and pancreas. They can be divided in tumours which produce and do not produce hormones. The latter are called non-functioning tumours. This study focused on non-functioning neuroendocrine tumours of the pancreas. If these are small, they can either be surgically removed or observed. Pancreatic surgery can lead to severe surgical complications. Observation is somewhat contra-intuitive in oncology as both doctors and patients may fear that the time window to successfully treat the tumour can be missed. In this study the authors reported on a large group of patients. Patients in both groups had very good survival. Both strategies are reasonable and should be discussed with patients