Isolated Demyelination of Corpus Callosum Following Hypoxia

Corpus callosum includes a large amount of axons with various degrees of myelination, interconnecting cerebral hemispheres. Tumors, demyelinating diseases, infections, trauma and metabolic diseases as well as vascular lesions may affect corpus callosum, often extending to other white matter areas of the brain. We describe the case of a 76 years old male patient with history of arterial hypertension, diabetes mellitus and normal pressure hydrocephalus, developing dysphagia during hospitalization. Ab-ingestis pneumonia caused brain hypoxia and coma; brain magnetic resonance disclosed isolated demyelination of corpus callosum that was not present before hypoxia. Compared to neurons and astrocytes, oligodendrocytes are reported as particularly sensitive to hypoxia. Respiratory involvement without blood flow impairment could have lead to a prevalent oligodendrocytes damage, resulting in a selective demyelination of corpus callosum. Our patient indeed evolved into persistent vegetative state and died five months after hypoxic episode. This case report could give some insight about in vivo brain susceptibility to hypoxic damage

Thrombosed external haemorrhoids: A clinician’s dilemma

Haemorrhoids are highly vascular submucosal cushions that underlie the distal rectal mucosa and contribute approximately 15-20% of the resting anal pressure, ensuring complete closure of the anal cana

Proctology in the COVID-19 era: handle with care

The Italian outbreak of COVID-19 was confirmed on 31 January 2020 when two COVID-19-positive cases were reported in Chinese tourists. At the beginning, the vast majority of cases were reported in the northern regions of Italy with establishment of the so-called ‘red zone’. On 9March 2020, the Italian prime minister declared a nationwide lockdown to strengthen the national health system (Sistema Sanitario Nazionale). Italy has one of the highest rates of infection and mortality in the worl

Effetto della terapia con onde d'urto radiali sul dolore e l'ipertonia muscolare: uno studio in doppio cieco in un gruppo di pazienti affetti da sclerosi multipla.

Effetto della terapia con onde d'urto radiali sul dolore e l'ipertonia muscolare: uno studio in doppio cieco in un gruppo di pazienti affetti da sclerosi multipla. Introduzione La sindrome del motoneurone superiore, caratterizzata da molteplici segni clinici, può essere dovuta a varie patologie: ictus, paralisi cerebrale infantile, sclerosi multipla, traumi cranici e tumori, per citare le più frequenti. La spasticità è uno dei segni clinici di questa sindrome e consiste in un aumento patologico del riflesso da stiramento. La caratteristica fondamentale della spasticità è la sua dipendenza dalla velocità dell'allungamento muscolare passivamente imposto dall'esaminatore: maggiore è tale velocità e maggiore è la risposta riflessa del muscolo. Tuttavia, nei pazienti affetti da sindrome del motoneurone superiore, l'aumento del tono muscolare è dovuto anche a modificazioni intrinseche del muscolo, dovute al fatto che esso tende a perdere la sua parte contrattile e ad aumentare le sue componenti fibrose (ipertono intrinseco). Clinicamente può essere molto difficile apprezzare in modo distinto queste due componenti dell'ipertono muscolare (spasticità ed ipertono intrinseco). Le onde d’urto, distinte in focali e radiali, sono delle onde acustiche ad alta energia, prodotte da specifici generatori, che sono state utilizzate nel trattamento dell'ipertono nei pazienti affetti da paralisi cerebrale infantile e nei pazienti affetti da ictus. Esse sono utili anche nella terapia del dolore, soprattutto nelle patologie che colpiscono il tendine e l'inserzione muscolo tendinea. E’ stato dimostrato che le onde d'urto producono bolle di cavitazione nei tessuti trattati. La cavitazione è una conseguenza della fase di pressione negativa durante la propagazione dell’onda. La rapida implosione delle bolle di cavitazione produce onde d’urto secondarie. Il meccanismo della cavitazione potrebbe giocare un ruolo di primo piano nell’azione delle onde d'urto focali e radiali. Nella speranza di combinare il duplice effetto della onde d'urto radiali sul dolore e l'ipertonia, nel presente studio esse sono state utilizzate per trattare l’ipertonia dolorosa dei muscoli estensori della caviglia (il muscolo tricipite surale) in un gruppo di soggetti affetti da sclerosi multipla (SM). Materiali e metodi I pazienti sono stati arruolati presso il Dipartimento di Neurologia dell’Università degli Studi di Genova, in accordo con i seguenti criteri: SM diagnosticata secondo i criteri di McDonald, con un punteggio maggiore di 4 alla Kurtzke Extended Disability Status Scale (EDSS); ipertonia dei muscoli estensori della caviglia; dolore durante la mobilizzazione della caviglia; nessuna ricaduta del quadro clinico e nessuna somministrazione di corticosteroidi e di tossina botulinica negli ultimi 6 mesi. Un totale di 120 soggetti (68 donne) sono stati valutati per l’idoneità all’inclusione nello studio. Alla fine della valutazione, 68 soggetti (40 donne; età media ± DS: 51,4 ± 12,2) hanno soddisfatto i criteri di inclusione e hanno partecipato allo studio. La misura principale di risultato (“primary outcome measure”) è stato il dolore riferito all’arto inferiore trattato, misurato utilizzando la scala visiva analogica per il dolore (VAS per il dolore). La misura secondaria di risultato (“secondary outcome measure”) è stato il tono muscolare degli estensori della caviglia, misurato in posizione supina mediante la scala di Ashworth modificata (MAS). Ulteriori misure di risultato sono state la forza dei muscoli della caviglia e la velocità nel cammino. La forza muscolare in estensione è stata misurata in accordo con il Medical Research Council (MRC) per la forza. La velocità nel cammino è stata rilevata tramite il 10-meter walking test (10-MWT). Le onde d'urto radiali sono state erogate utilizzando il dispositivo BTL-6000 SWT Topline Unit (BTL Italy). I pazienti sono stati trattati su un solo lato. La terapia con onde d’urto radiali è stata erogata in 4 sessioni, con una settimana di intervallo tra una sessione e l’altra. Durante ogni sessione, venivano somministrati 2000 colpi ai muscoli estensori della caviglia ed al tendine d’Achille. La frequenza utilizzata è stata di 4 Hz, con una pressione di 1,5 Bar. Il trattamento placebo è stato somministrato utilizzando la stessa apparecchiatura, regolata per erogare la stessa energia. Si è impedito però che le onde d’urto raggiungessero i muscoli bersaglio grazie a un sottile cuscino di gommapiuma posto sull’applicatore metallico. La valutazione clinica è stata condotta: prima del trattamento (T0); una settimana dopo la prima sessione (T1); una settimana dopo l'ultima sessione (T2) e 4 settimane dopo l’ultima sessione (T3). Risultati 34 soggetti hanno ricevuto il trattamento con onde d'urto e 34 soggetti hanno ricevuto il trattamento placebo. La tabella 1 e la tabella 2 mostrano le caratteristiche demografiche e cliniche pre-trattamento (T0) dei 68 soggetti arruolati nello studio. L’analisi statistica non ha evidenziato nessuna differenza significativa tra i soggetti trattati con onde d'urto e quelli trattati con il placebo per quanto riguarda la distribuzione dell’età, i punteggi EDSS e le misure di risultato (VAS, MAS, MRC per la forza e 10-MWT). La tabella 2 mostra l'andamento temporale degli indici di risultato. Dopo le onde d'urto, i punteggi VAS sono significativamente diminuiti in tutti i controlli, raggiungendo il loro massimo effetto a T2, quando l’85% dei soggetti ha avuto una diminuzione di almeno 1 punto. I valori della MAS sono diminuiti significativamente solo a T2, mentre non sono state osservate modificazioni significative della forza e della velocità del cammino. A seguito del trattamento placebo, nessun cambiamento significativo è stato evidenziato rispetto ai valori di partenza. Discussione Il principale risultato di questo studio è stato l'effetto delle onde d'urto sul dolore. Questo effetto, che ha raggiunto il suo massimo una settimana dopo l’ultima sessione di trattamento (T2), era già presente una settimana dopo la prima sessione (T1) ed è persistito per quattro settimane dall’ultima sessione (T3). Nel momento di massima riduzione del dolore (T2), si è osservata una riduzione del tono muscolare. Le onde d'urto non hanno avuto alcuna influenza sulla forza muscolare e sulla velocità del cammino. Nessun effetto è stato evidenziato a seguito del trattamento placebo. Il presente studio dimostra che la terapia con onde d'urto può ridurre il dolore e il tono muscolare in pazienti affetti da SM, senza alcun effetto sulla forza muscolare. Per ottimizzare l’effetto riportato ed ottenere risultati funzionali, è probabile che la terapia con onde d'urto debba essere integrata all’interno di un programma riabilitativo, dove la fisioterapia dovrebbe essere costituita dall’allungamento attivo e passivo dei muscoli ipertonici, allenamento della forza dei muscoli antagonisti, miglioramento della mobilità funzionale e rieducazione al corretto schema del passo. Tabelle Tabella 1. Caratteristiche demografiche e cliniche dei soggetti prima del trattamento (T0) Soggetti trattati con RSWT Soggetti trattati con placebo Età, anni, media ± DS 51.74 ± 11.29 51.00 ± 13.17 Sesso, M/F, n 14/20 16/18 Lato trattato, D/S, n 16/18 16/18 EDSS, media ± DS 6.60 ± 0.78 6.15 ± 1.23 RSWT: Radial Shock Wave Therapy; DS: Deviazione Standard; M: maschio; F: femmina; n: numero; D: destra; S: sinistra; EDSS: Expanded Disability Status Scale. Tabella 2. Misure di outcome (VAS, MAS, 10-MWT and MRC) distinte nelle differenti fasi temporali VAS (media ± DS) MAS (media ± DS) MRC (media ± DS) 10-MWT Soggetti trattati con RSWT T0 6.49 ± 1.60 2.68 ± 0.77 1.88 ± 1.14 34.17 ± 12.68 T1 5.22 ± 1.53 (p<0.0001) 2.62 ± 0.74 (p= 1) 1.94 ± 1.15 (p= 1) 33.14 ± 12.79 (p= 0.7) T2 3.44 ± 2.07 (p<0.0001) 1.90 ± 0.98 (p<0.0001) 1.99 ± 1.14 (p= 0.1) 32.25 ± 12.16 (p= 0.07) T3 5.21 ± 1.80 (p=0.0004) 2.56 ± 0.92 (p= 0.2) 1.87 ± 1.14 (p= 1) 33.05 ± 12.74 (p= 0.3) Soggetti trattati con placebo T0 6.15 ± 1.23 2.56 ± 0.99 2.12 ± 0.98 39.11 ± 14.91 T1 5.62 ± 1.26 (p= 0.08) 2.50 ± 1.05 (p= 0.4) 2.15 ± 0.74 (p= 1.0) 39.63 ± 13.67 (p= 0.8) T2 5.68 ± 1.49 (p= 0.2) 2.44 ± 1.05 (p= 0.2) 2.18 ± 0.67 (p= 0.8) 39.81 ± 14.30 (p= 0.8) T3 5.68 ± 1.30 (p= 0.2) 2.47 ± 1.08 (p= 0.3) 2.18 ± 0.80 (p= 0.8) 40.37 ± 14.39 (p= 0.7) RSWT: Radial Shock Wave Therapy; DS: Deviazione Standard; VAS: Visual Analogue Scale; MAS: Modified Ashworth Scale; MRC: Medical Research Council; 10-MWT: Ten-Meter Walking Test

Martius' flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn's disease, endometriosis and a mullerian anomaly

Background: Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn's disease that negatively affects patients' social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options. Case presentation: We describe a 31-year-old female patient with a Crohn's disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient's medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius' flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy. Conclusion: Martius' flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn's disease. The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate

Incobotulinum booster injections in patients with spasticity and dystonia after stroke

Background.\u2013 Previous results in patients injected with abobotulinum toxin A and onabotulinum toxin A have shown that injection intervals shorter than 2 months may increase the risk for neutralising antibody formation and treatment non-response. As a result, for the last 10 years, we have adopted longer intervals to treat patients with spasticity and/or dystonia secondary to stroke. It has been showed that incobotulinum toxin A does not induce neutralising antibodies. Observations.\u2013 Methods.\u2013 Ten patients with spasticity and/or dystonia due to stroke underwent a booster injection one month after the first injection. The clinical results were compared to those previously obtained in the same 10 patients using a single injection. Secondary dystonia was evaluated using the Unified Dystonia Rating Scale (UDRS), while spasticity was evaluated according to the Modified Ashworth Scale (MAS). Results.\u2013 They showed that the booster injection protocol induced an improvement in 8 subjects. In the remaining 2 subjects, we did not find any difference between the results obtained using the single and the booster injection protocols. Conclusions.\u2013 The use of a booster injection improve the clinical outcome in patients with spasticity and/or dystonia after stroke, allowing an optimal treatment of those muscles that poorly responded to the first injection

The role of physical activity against chemotherapy-induced peripheral neuropathy: a narrative review

Several studies investigated the side effect of adjuvant cancer treatments, and different types of preventive techniques or treatments have been assessed. Chemotherapy-induced peripheral neuropathy (CIPN) is the most common neurological side effect. Exercise training has been widely studied as an adjuvant therapy to prevent CIPN and improve post-chemotherapy functional outcome and quality of life (QoL). This narrative review aims to summarize the data obtained from the latest studies about physical activity (PA) for the prevention and treatment of CIPN and associated QoL measures. Literature research was conducted to obtain studies including PA interventions for patients with CIPN. Ten studies met inclusion criteria and were therefore summarized and discussed, focusing on exercise type and functional outcome. It seems clear that, regardless of the type of exercise, PA plays a positive role in the treatment of CIPN, providing a significant symptom improvement. There has been no standardization of type, quantity, and intensity of PA administered to the subjects in the various studies probably due to a physiological difference between samples, grade of neuropathy, and difference among therapies

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problemIn the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. Proposed solutionsThe objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. ConclusionsIt's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery

Temporal Asynchrony but Not Total Energy Nor Duration Improves the Judgment of Numerosity in Electrotactile Stimulation

Stroke patients suffer from impairments of both motor and somatosensory functions. The functional recovery of upper extremities is one of the primary goals of rehabilitation programs. Additional somatosensory deficits limit sensorimotor function and significantly affect its recovery after the neuromotor injury. Sensory substitution systems, providing tactile feedback, might facilitate manipulation capability, and improve patient's dexterity during grasping movements. As a first step toward this aim, we evaluated the ability of healthy subjects in exploiting electrotactile feedback on the shoulder to determine the number of perceived stimuli in numerosity judgment tasks. During the experiment, we compared four different stimulation patterns (two simultaneous: short and long, intermittent and sequential) differing in total duration, total energy, or temporal synchrony. The experiment confirmed that the subject ability to enumerate electrotactile stimuli decreased with increasing the number of active electrodes. Furthermore, we found that, in electrotactile stimulation, the temporal coding schemes, and not total energy or duration modulated the accuracy in numerosity judgment. More precisely, the sequential condition resulted in significantly better numerosity discrimination than intermittent and simultaneous stimulation. These findings, together with the fact that the shoulder appeared to be a feasible stimulation site to communicate tactile information via electrotactile feedback, can serve as a guide to deliver tactile feedback to proximal areas in stroke survivors who lack sensory integrity in distal areas of their affected arm, but retain motor skills

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery