Search

BACKGROUND AND PURPOSE: Mitochondrial neurogastrointestinal encephalopathy is a rare disorder due to recessive mutations in the thymidine phosphorylase gene, encoding thymidine phosphorylase protein required for mitochondrial DNA replication. Clinical manifestations include gastrointestinal dysmotility and diffuse asymptomatic leukoencephalopathy. This study aimed to elucidate the mechanisms underlying brain leukoencephalopathy in patients with mitochondrial neurogastrointestinal encephalopathy by correlating multimodal neuroradiologic features to postmortem pathology. MATERIALS AND METHODS: Seven patients underwent brain MR imaging, including single-voxel proton MR spectroscopy and diffusion imaging. Absolute concentrations of metabolites calculated by acquiring unsuppressed water spectra at multiple TEs, along with diffusion metrics based on the tensor model, were compared with those of healthy controls using unpaired t tests in multiple white matters regions. Brain postmortem histologic, immunohistochemical, and molecular analyses were performed in 1 patient. RESULTS: All patients showed bilateral and nearly symmetric cerebral white matter hyperintensities on T2-weighted images, extending to the cerebellar white matter and brain stem in 4. White matter, N -acetylaspartate, creatine, and choline concentrations were significantly reduced compared with those in controls, with a prominent increase in the radial water diffusivity component. At postmortem examination, severe fibrosis of brain vessel smooth muscle was evident, along with mitochondrial DNA replication depletion in brain and vascular smooth-muscle and endothelial cells, without neuronal loss, myelin damage, or gliosis. Prominent periependymal cytochrome C oxidase deficiency was also observed. CONCLUSIONS: Vascular functional and histologic alterations account for leukoencephalopathy in mitochondrial neurogastrointestinal encephalopathy. Thymidine toxicity and mitochondrial DNA replication depletion may induce microangiopathy and blood-brain-barrier dysfunction, leading to increased water content in the white matter. Periependymal cytochrome C oxidase deficiency could explain prominent periventricular impairment.

n.a.

We describe the first case of hyperacute reversible encephalopathy following COVID-19 vaccination. A patient presented with acute onset encephalopathy, mainly characterized by agitation and confusion, rapidly responsive to high dosage steroid therapy and complete remission within 3 days from onset. The clinical manifestation was related with systemic and CSF cytokine hyperproduction, responsive to steroid therapy. Although the occurrence of encephalopathy after vaccination may be just a casual temporal association, we speculate that the cytokine-storm could be the result of an excessive innate immune response against the vaccine, in a predisposed patient susceptible to autoimmunity., Graphical abstract Unlabelled Image

"Some patients find it difficult to be in the present because they are stuck in the past; others, by contrast, struggle to remain connected with the past and are suspended in a so-called present that is effectively atemporal, that is out of time”.1 (p.360) For psychoanalysts, the most profound and ultimately ethical way that we can help individuals, is by helping them know themselves. This involves discovering how they were shaped by their past and how their ongoing self-experience cannot be understood in isolation from its constitutive contexts. Psychoanalysts help patients explore foundational questions such as: ‘Who am I?’ ‘How did I get here?’ ‘How am I implicated in my own suffering?’ ‘How can I grow and flourish and truly engage with my life?’. The answers to these questions emerge from a detailed exploration of the persons lived relational history, their current social and relational context and the political systems within which they are embedded. It is via this expansion of self-awareness that individuals can access agency and true freedom of choice. The clinical approach presented by Notini et al 2 is grounded in a completely different, radically decontextualised understanding of human experience. Their conceptualisation of Phoenix’s gender identity is ahistorical and atemporal: it is indeed ‘out of time’. For these authors, gender identity is assumed to be an immutable core essence, much like Ehrensaft’s3 (p.341) ‘true gender self….there from birth’. It simply ‘is’. This is a …

Purpose: Antibodies to glutamic acid decarboxylase (GAD-Abs) have been associated with several conditions, rarely involving the autonomic nervous system. Here, we describe two patients complaining of autonomic symptoms in whom a post-ganglionic autonomic neuropathy has been demonstrated in association with significantly elevated serum and CSF GAD-Abs levels. Methods: Patients underwent nerve conduction studies, sympathetic skin response testing, evaluation of autonomic control of the cardiovascular system and skin biopsy. Also, serum screening to exclude predisposing causes of peripheral neuropathy was performed. Anti-GAD65 antibodies were evaluated in serum and CSF. Results: GAD-Abs titer was increased in both serum and CSF in both patients. Sympathetic skin response was absent and skin biopsy revealed a non-length-dependent small-fiber neuropathy with sympathetic cholinergic and adrenergic post-ganglionic damage in both patients. Nerve conduction studies and evaluation of autonomic control of the cardiovascular system were normal in both patients. Both patients were treated with steroids with good, but partial, (patient 2) recovery of the autonomic dysfunctions. Conclusions: Although the pathophysiological mechanisms involved are not fully defined, GAD-abs positivity in serum and CSF should be searched in patients with autonomic neuropathy when no other acquired causes are evident. This positivity may help to clarify autoimmune etiology and, subsequently, to consider immunomodulatory treatment.

PurposePortal vein thrombosis (PVT) is generally recognized as a prognostic factor in HCC. Our purpose is to assess and compare the survival of patients with PVT and without PVT, after Y-90 Trans-Arterial Radio-Embolization (TARE) of unresectable HCC, unresponsive to other loco-regional treatments.Materials and methodsBetween November 2005 and November 2012, Y-90 resin-based TARE was performed in an IRB-approved prospective protocol, on 89 patients with unresectable HCC. 33/89 patients had PVT, the remaining 56 were resistant-to-cTACE or underwent TARE as a downstaging therapy. All patients were studied with Multi-Detector Computed Tomography (MDCT), angiography, 99mTc-MAA-scintigraphy and liver biopsy. Gastro-duodenal artery was embolized in most cases. Proton-Pump Inhibitors were administered to prevent gastritis and ulcers. χ2 test with Yates correction and log rank test were used to compare the two proportions and Kaplan-Meier survival curves, respectively.ResultsThe average activity administered was 1.7 ± 0.4 GBq. After the treatment, CTCAE grade 2 adverse events occurred in 46% (41/89) patients: in particular, fever and abdominal pain were found in 25 and 16 patients, respectively. No major side-effect was observed. According to mRECIST criteria, partial response or complete response was found in 70% of patient three months after the treatment, and in 90.5% nine months after the treatment. No significant difference was found in survival of patients with PVT compared to those without PVT (p-value = 0.672). A complete regression of PVT was observed in almost half patients (13/27, 48.1%).ConclusionsPortal vein invasion does not affect survival in advanced stage HCC-patients undergoing TARE using Y-90 resin-based microspheres. Y90 procedure is associated with regression of portal vein tumor thrombus.

A 62-year-old man presented to the Emergency Department of Sant'Orsola-Malpighi University Hospital in Bologna, Italy, because of a rapidly progressive cognitive decline. He had recently come back to Italy after a 3-month journey in Brazil because relatives found him confused while speaking over the phone. Because of global slowing, disorientation, and confabulation, which developed over the previous 2 months, he underwent a brain MRI in Brazil, which showed cortical atrophy and multiple white matter lesions with no contrast enhancement. No further clinical information about the medical assessment in Brazil was available.

Investigating the behaviour of buildings is extremely useful for planning interventions aimed at their safeguarding, although hardly affordable over large urbanized areas. In this regard, DInSAR-derived building settlements can provide a valuable contribution. This paper presents a procedure tailored for deriving empirical fragility curves for buildings that might be affected by differential settlements on the basis of the combined use of DInSAR data and the results of damage surveys. The case studies deal with two municipalities in The Netherlands where masonry buildings mainly rest on soft soils (i.e. peats and organic clays). The behaviour of buildings with different foundation types (i.e. shallow and deep) is analyzed and a check of the performance of a restored foundation is carried out via the analysis of pre- and post-intervention DInSAR-derived settlement trends.

Objective:To reflect on the role of psychiatry in authorising physical treatments for Gender Dysphoria and to examine the quality of evidence for gender-reassignment.Method:A Medline search was performed with the subject term “transsexualism” or “gender dysphoria” and “outcome” or “follow-up” in the title. Studies published from 2005 onwards reporting psychosocial outcomes were selected for review.Results:Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide.Conclusion:The author raises questions about the implications for ethical treatment of transgender individuals.

Truncating mutations in PRNP have been associated with heterogeneous phenotypes ranging from chronic diarrhea and neuropathy to dementia, either rapidly or slowly progressive. We identified novel PRNP stop-codon mutations (p.Y163X, p.Y169X) in two Italian kindreds. Disease typically presented in the third or fourth decade with progressive autonomic failure and diarrhea. Moreover, one proband (p.Y163X) developed late cognitive decline, whereas some of his relatives presented with isolated cognitive and psychiatric symptoms. Our results strengthen the link between PRNP truncating mutations and systemic abnormal PrP deposition and support a wider application of PRNP screening to include unsolved cases of familial autonomic neuropathy.

In a muscle fiber, a vacuole is a membrane-bound area, which may contain various cellular components or enzymes. The type and function of a vacuole varies, and their properties can be a useful path...

Very few cases of patients with myasthenia gravis (MG) who later developed amyotrophic lateral sclerosis (ALS) have been described, although some studies showed that significantly more cases than expected have ALS associated with a prior diagnosis of autoimmune diseases. Our aim was to investigate whether the association of ALS and MG was higher than expected in a population-based study and to describe the clinical features characterizing these patients. In Emilia Romagna Region of Italy, a prospective registry has been collecting all incident ALS cases since 1.1.2009. For each patient, detailed clinical information is collected by caring physicians, including comorbidities. From 1.1.2009 to 31.12.2014, 671 patients were diagnosed with ALS; five patients (0.75%) were also affected by MG. Considering Western Countries incidence rates the occurrence of both the diseases should be a really exceptional event (7.5/109), compared to our findings (1.87/107) (p

Vários problemas ambientais e de saúde, principalmente nos grandes centros urbanos estão associados à forma com que lidamos com a produção, descarte, armazenamento e reciclagem dos resíduos produzidos pela população e pelas indústrias. Norteado nesse contexto foi realizado o levantamento teórico por meio de uma pesquisa bibliográfica que engloba temas relacionados ecodesign, projeto do ciclo de vida e reciclagem e reutilização dos materiais. Entretanto, nem todos os materiais têm valor comercial, como por exemplo, o plástico EVA (Etileno Acetato de Vinila). Este plástico é o refugo do processo produtivo de uma indústria gráfica que anualmente descarta grandes quantidades deste material. Baseado nos temas relacionados ao trabalho propõe-se a reutilização deste material em um ciclo de vida de outro produto, utilizando como matéria prima o EVA descartado na fase de pré-produção

Aim of the study was to characterize KPC-producing Escherichia coli (KPC-Ec) clinical isolates among a Northern Italy Long-Term Care and Rehabilitation Facility (LTCRF) residents. Thirteen consecutive non repeated MDR E. coli isolates showing ertapenem Minimum Inhibitory Concentrations (MICs)0.5 mg/L, collected during the period March 2011 - May 2013 from ASP "Redaelli" inpatients, were investigated. The bla KPC/CTX-M/SHV/TEM/OXA genes were identified by PCR and sequencing. KPC-Ec isolates underwent phylotyping, Pulsed-Field Gel Electrophoresis (PFGE), multilocus sequence typing (MLST) and repetitive sequence-based PCR (rep-PCR) profiling. Incompatibility groups analysis and conjugation were also performed. Eleven out of 13 isolates, resulted bla KPC-type positive, were consistently resistant to third generation cephalosporins, fluoroquinolones and trimethoprim-sulphametoxazole (84.6 %), retaining susceptibility to colistin (EUCAST guidelines). At least n = 4/11 of KPC-Ec patients received ≥48 h of meropenem therapy. Sequencing identified 9 bla KPC-2, 1 bla KPC-3 and 1 bla KPC-8 determinants. KPC-Ec plasmids belonged to IncF group (FIIk replicon); conjugation confirmed bla KPC/TEM-1/OXA-9 genes transferability for 10 KPC-Ec. Although three pulsotypes (A, B, C) were identified, all KPC-Ec belonged to phylogenetic group B2. Clone B (B-B5) caused an outbreak of infection involving nine inpatients at five wards. Rep-PCR showed relatedness for seven representative KPC-Ec isolates. Here we report a LTCRF outbreak caused by a ST131-B2 E. coli associated with bla KPC-2 and bla KPC-8 genes, and the emergence of the new ST3948. Elderly people with co-morbidities are at risk for ST131 colonization. KPC-Ec clones local monitoring appears essential both to avoid their spreading among healthcare settings, and to improve therapeutic choices for LTCRF residents.

Mitochondrial neuro-gastro-intestinal encephalomyopathy (MNGIE) is a rare and unavoidably fatal disease due to mutations in thymidine phosphorylase (TP). Clinically it is characterized by gastrointestinal dysfunction, malnutrition/cachexia and neurological manifestations. MNGIE diagnosis remains a challenge mainly because of the complexity and rarity of the disease. Thus, our purposes were to promote a better knowledge of the disease in Emilia-Romagna region (ERR) by creating an accurate and dedicated network; to establish the minimal prevalence of MNGIE in Italy starting from ERR. Blood TP activity level was used as screening test to direct candidates to complete diagnostic work-up. During the study period of 1 year, only 10/71 units of ERR recruited 14 candidates. Their screening did not show TP activity changes. An Italian patient not resident in ERR was actually proved to have MNGIE. At the end of study in Italy there were nine cases of MNGIE; thus, the Italian prevalence of the disease is ~0.15/1,000,000 as a gross estimation. Our study confirms that MNGIE diagnosis is a difficult process which reflects the rarity of the disease and, as a result, a low level of awareness among specialists and physicians. Having available novel therapeutic options (e.g., allogenic hematopoietic stem cell transplantation and, more recently, liver transplantation) and an easy screening test, an early diagnosis should be sought before tissue damage occurs irreversibly.

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a fatal, recessive disease caused by mutations in the gene encoding thymidine phosphorylase, leading to reduced enzymatic activity, toxic nucleoside accumulation, and secondary mitochondrial DNA damage. Thymidine phosphorylase replacement has been achieved by allogeneic hematopoietic stem cell transplantation, a procedure hampered by high mortality. Based on high thymidine phosphorylase expression in the liver, a 25-year-old severely affected patient underwent liver transplantation. Serum levels of toxic nucleosides rapidly normalized. At 400 days of follow-up, the patient's clinical conditions are stable. We propose liver transplantation as a new therapy for MNGIE. Ann Neurol 2016;80:448-455.

Detailed information is still lacking on structure and duration of calls of diurnal birds of prey as well on their vocal repertoire. The Lanner Falcon (Falco biarmicus) is considered a shy less-vociferous species but no quantitative data exist. Field evidence demonstrates that in the last decades this falcon did not improve its threatened status in Italy. We investigated call frequencies and their durations to ascertain the effectiveness of these signals, especially during the breeding season. In particular, if calls are honest signals about the genetic quality of males. We carried out this study during two breeding seasons in eastern Sicily where we monitored 25 nesting attempts at 19 breeding sites. During 114 observational sessions, we recorded (1) which sex uttered calls, (2) type of vocalisation (wailing and creaking calls) and (3) bird positions (flying or perched). In addition, we recorded duration of each vocal event because it seems to be significantly correlated with male quality. We checked nests annually to ascertain the number, age and gender of nestlings. Lanner mates employ calls mainly in crucial reproductive stages (courtship, incubation, the first week after hatching and when young are fledging) optimising their efforts. In addition, males performing shorter vocal events produce broods significantly smaller in size and with a sex ratio biased towards females. In addition, they seem to desert the breeding site in the subsequent year. We suppose that in Italian fragmented breeding populations of Lanners, call structure and rates can predict population viability.

Hepatocellular carcinoma (HCC) is a major health problem worldwide, affecting more than 600,000 new patients per year. Curative treatments are available in a small percentage of patients, while most of them present in stages requiring locoregional treatments such as thermoablation, transarterial chemoembolization, and/or radioembolization. These therapies result in specific imaging features that the general radiologist has to be aware of in order to assess the response to treatment and to correctly manage the follow-up of treated patients. Multiphasic helical computed tomography has become a popular imaging modality for detecting hypervascular tumors and characterizing liver lesions. On this basis, many staging and diagnostic systems have been proposed for evaluating response to all different existing strategies. Radiofrequencies and microwaves generate thermoablation of tumors, and transarterial chemoembolization exploits the double effect of the locoregional administration of drugs and embolizing particles. Eventually radioembolization uses a beta-emitting isotope to induce necrosis. Therefore, the aim of this comprehensive review is to analyze and compare CT imaging appearance of HCC after various locoregional treatments, with regard to specific indications for all possible procedures.

Pretendeu-se, com este trabalho, estudar a síntese e o desenvolvimento de nanopartículas de prata, utilizando o método de Turkevich com algumas modificações. Dada a importância dessas nanopartículas no atual desenvolvimento científico, é de grande valia o melhor entendimento dos mecanismos que regem a síntese e desenvolvimento das nanopartículas de prata. Neste método, nitrato de prata sofre redução pelo citrato de sódio, numa mistura aquecida e bem agitada, para formar as nanopartículas. Amostras dessa mistura foram coletadas em vários intervalos de tempo, e reservadas para análises de concentração de prata por ICPAES, absorbância UV-Vis, imagens de MEV e distribuição de tamanhos por DLS. Com essas análises, foi possível estabelecer uma relação direta entre os valores de absorbância e os de conversão de prata. Também foi possível propor uma rota de desenvolvimento das nanopartículas, mostrando que, durante esse desenvolvimento, as partículas apresentam diferentes morfologias, tamanhos e tendência a formar aglomerados. Dependendo da aplicação das nanopartículas de prata, é possível interromper a reação quando elas apresentarem as características mais favoráveis. It was intended, with this work, to study the synthesis and development of silver nanoparticles using the Turkevich method with some modifications. Given the importance of these nanoparticles in the current scientific development, it is of great value the better understanding of the mechanisms governing the synthesis and growth of silver nanoparticles. In this method, silver nitrate is reduced by sodium citrate, in a well-stirred and heated mixture to form nanoparticles. Samples of this mixture were taken at various time intervals, and reserved for analysis of silver concentration by ICP-AES, UV-Vis absorbance, SEM images and size distribution by DLS. With these analyzes, it was possible to establish a direct relationship between the absorbance values and the conversion of silver. It was also possible to propose a synthesis and growth pathway of the silver nanoparticles, showing that during this development, the particles have different morphologies, sizes and tendencies to form agglomerates. Depending on the application of silver nanoparticles, it is possible to stop the reaction when they have the most favorable characteristics.

Catathrenia (nocturnal groaning) is a rare condition characterized by monotonous irregular groans occurring during sleep. Ten patients (five women; mean age: 27 +/- 7.4 years, range: 15-41) with sleep-related groaning persisting for years or decades and normal daytime fibreoptic laryngoscopy and respiratory function tests underwent videopolysomnographic recording (VPSG) analysing their respiratory patterns during sleep. After the VPSG, all patients were clinically followed up for a mean period of 4.9 +/- 3.5 years. On VPSG, all patients showed nocturnal groaning during NREM sleep and particularly during REM sleep stages. Groaning was associated with disproportionate prolonged expiration causing reduced breathing rate without oxygen desaturation. The breathing pattern with prolonged expiration and sound production alternated with a normal respiratory pattern without groaning. Endoesophageal pressure during groaning showed mildly positive swings at the initial phase of expiration suggesting a partial mild expiratory upper airway obstruction. At the end of the follow-up period, all patients reported persistent nocturnal groaning but no other clinical manifestations. Groaning confined to sleep alternating with normal breathing and the absence of long-term clinical consequences suggest that catathrenia is because of an abnormality of the internal respiratory drive system, possibly related to persistence of a neonatal (vestigial) type of breathing pattern.

We describe a 33-year-old man who presented with lip and tongue nibbling and bleeding during sleep. Videopolysomnography revealed myoclonic jerks involving the masticatory and facial muscles recurring mainly during NREM sleep. There was no tonic EMG masticatory activity typical of bruxism. EMG analysis demonstrated the recruitment of V- to VII innervated muscles and, in half of the episodes, also the sternocleidomastoideus. Our patient had sleep-related faciomandibular myoclonus (SFMM) with spontaneous jerks of oromasticatory and cervical muscles, occurring only during sleep. Tooth grinding, temporomandibular joint pain, abnormal tooth mobility, tooth wear, and other dental problems were clinically absent. We propose that, on the basis of the clinical and EMG features, SFMM may be considered a distinct disorder and different from sleep bruxism.

Objective To study sleep–wake and body core temperature (BCT) circadian rhythms in patients with multiple sclerosis (MS)-associated with chronic fatigue. Methods Six relapsing–remitting MS patients with chronic fatigue underwent 48 consecutive hours polysomnography (PSG) with BCT measurement, followed by a Multiple Sleep Latency Test (MSLT). All patients were relapse- and drug-free. Mood depression, brain and cervical cord enhanced MRI, dynamic spirometry and Fatigue Severity Scale (FSS) were assessed just before PSG. Results In all patients mood depression was absent and dynamic spirometry normal, but FSS confirmed fatigue. MRI showed non-enhancing lesions. Nocturnal sleep was characterized by normal architecture and mean sleep efficiency was only slightly reduced. Arousal index was normal and periodic limb movements during sleep (PLMS) were present in four patients, with an increased index (PLMS- I ) in only two of them. Upon MSLT, mean sleep latency was normal in all patients with one sleep onset REM period in one patient. All patients displayed a normal BCT 24-h rhythm. Mesor, amplitude and acrophase of BCT rhythm did not show significant differences between MS and controls. Conclusions We found substantially normal sleep–wake and BCT rhythmicity in six patients with MS and fatigue. Non-restorative sleep and abnormal BCT regulation were unlikely mechanisms of chronic fatigue in our MS patients. Significance Subjective fatigue and abnormal sleep and BCT can be independent manifestation in MS patients. The findings support the notion that objective measures of fatigue comparable to the MSLT for sleepiness do not exist.

Il lavoro svolto riguarda la misurazione dell'altezza dell'osso perimplantare nel mascellare superiore nella zona dei diatorici dove, contestualmente all'inserzione dell'impianto dentale, è stato eseguito un grande rialzo del seno mascellare con innesto di osso autologo. La valutazione è stata fatta misurando l'altezza dell'osso parallela all'asse maggiore dell'impianto, direttamente su ortopantomografia digitale. La misurazione è stata effettuata al T0 e cioè successivamente all'inserzione implantare; e al T1, cioè dopo un follow up variabile compreso tra 2 e 6 anni. I risultati hanno mostrato come nel tempo l'innesto di osso si è mantenuta nel tempo, intengrandosi perfettamente con l'osso circostante senza intaccare in maniera importante l'altezza totale dell'osso perimplantare.

Background Multidrug resistant microorganisms are a growing challenge and new substances that can be useful to treat infections due to these microorganisms are needed. Silver nanoparticle may be a future option for treatment of these infections, however, the methods described in vitro to evaluate the inhibitory effect are controversial. Results This study evaluated the in vitro activity of silver nanoparticles against 36 susceptible and 54 multidrug resistant Gram-positive and Gram-negative bacteria from clinical sources. The multidrug resistant bacteria were oxacilin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., carbapenem- and polymyxin B-resistant A. baumannii, carbapenem-resistant P. aeruginosa and carbapenem-resistant Enterobacteriaceae. We analyzed silver nanoparticles stabilized with citrate, chitosan and polyvinyl alcohol and commercial silver nanoparticle. Silver sulfadiazine and silver nitrate were used as control. Different methods were used: agar diffusion, minimum inhibitory concentration, minimum bactericidal concentration and time-kill. The activity of AgNPs using diffusion in solid media and the MIC methods showed similar effect against MDR and antimicrobial-susceptible isolates, with a higher effect against Gram-negative isolates. The better results were achieved with citrate and chitosan silver nanoparticle, both with MIC90 of 6.75 μg mL−1, which can be due the lower stability of these particles and, consequently, release of Ag+ ions as revealed by X-ray diffraction (XRD). The bactericidal effect was higher against antimicrobial-susceptible bacteria. Conclusion It seems that agar diffusion method can be used as screening test, minimum inhibitory concentration/minimum bactericidal concentration and time kill showed to be useful methods. The activity of commercial silver nanoparticle and silver controls did not exceed the activity of the citrate and chitosan silver nanoparticles. The in vitro inhibitory effect was stronger against Gram-negative than Gram-positive, and similar against multidrug resistant and susceptible bacteria, with best result achieved using citrate and chitosan silver nanoparticles. The bactericidal effect of silver nanoparticle may, in the future, be translated into important therapeutic and clinical options, especially considering the shortage of new antimicrobials against the emerging antimicrobial resistant microorganisms, in particular against Gram-negative bacteria.

Aim of the study was to characterize KPC-producing Escherichia coli (KPC-Ec) clinical isolates among a Northern Italy Long-Term Care and Rehabilitation Facility (LTCRF) residents. Thirteen consecutive non repeated MDR E. coli isolates showing ertapenem Minimum Inhibitory Concentrations (MICs) >0.5 mg/L, collected during the period March 2011 – May 2013 from ASP “Redaelli” inpatients, were investigated. The bla KPC/CTX-M/SHV/TEM/OXA genes were identified by PCR and sequencing. KPC-Ec isolates underwent phylotyping, Pulsed-Field Gel Electrophoresis (PFGE), multilocus sequence typing (MLST) and repetitive sequence-based PCR (rep-PCR) profiling. Incompatibility groups analysis and conjugation were also performed. Eleven out of 13 isolates, resulted bla KPC-type positive, were consistently resistant to third generation cephalosporins, fluoroquinolones and trimethoprim-sulphametoxazole (84.6 %), retaining susceptibility to colistin (EUCAST guidelines). At least n = 4/11 of KPC-Ec patients received ≥48 h of meropenem therapy. Sequencing identified 9 bla KPC-2, 1 bla KPC-3 and 1 bla KPC-8 determinants. KPC-Ec plasmids belonged to IncF group (FIIk replicon); conjugation confirmed bla KPC/TEM-1/OXA-9 genes transferability for 10 KPC-Ec. Although three pulsotypes (A, B, C) were identified, all KPC-Ec belonged to phylogenetic group B2. Clone B (B-B5) caused an outbreak of infection involving nine inpatients at five wards. Rep-PCR showed relatedness for seven representative KPC-Ec isolates. Here we report a LTCRF outbreak caused by a ST131-B2 E. coli associated with bla KPC-2 and bla KPC-8 genes, and the emergence of the new ST3948. Elderly people with co-morbidities are at risk for ST131 colonization. KPC-Ec clones local monitoring appears essential both to avoid their spreading among healthcare settings, and to improve therapeutic choices for LTCRF residents.

Background. Borderline personality disorder (BPD) is a serious mental illness. Due to scepticism about the effectiveness of its treatment, the care of these patients is neglected. In this study we evaluated the effect of treatment 5 years after its ending, of patients with BPD. Method. Thirty subjects were treated twice weekly for 1 year by psychotherapy based on the ‘Conversational Model ’ of Hobson. Outcome measures included time in hospital, number of episodes of violence and self-harm, number of medical appointments, drug use and work history. A ‘morbidity budget ’ made up of these items was collated for the year before treatment, the year following treatment, and for the year preceding the 5-year follow-up. Additional measures included DSM-III criteria and a self-report of symptoms. These outcomes were compared to a hypothetical natural history of BPD constructed from the DSM scores of 150 borderline patients aged between 18 and 52 years. Results. Except for one measure, the improvements evident 1 year following treatment were maintained 4 years later. This improvement was not predicted by the hypothetical natural history. Conclusion. A particular form of treatment of BPD has relatively long-lasting, beneficial effects.

Background: Transcatheter arterial procedures (TAP) have been widely used to treat hepatocellular carcinoma (HCC) in several clinical settings (advanced and neoadjuvant), and contraindications and secondary effects have been clearly described. However, it is still unclear which patients should be selected for treatment, which procedures should be used, in particular whether or not to add an antiblastic agent to embolization, and if the treatment provides a survival advantage in patient with HCC. Methods: We conducted a Medline search for all study reports published until May 2002. Data from randomised studies were evaluated in detail. Results: Data on the use of TAP for the treatment of unresectable HCC mainly come from retrospective studies that are difficult to compare because of the lack of standardized procedures. Some prognostic systems have been proposed in order to improve the selection of the patients that can benefit from treatment. While the effects in terms of tumour response are clearly documented, the results in terms of survival are still unclear. Conclusions: The real impact of TAP on survival remains to be determined in all clinical settings. The very few published prospective randomised trials are underpowered and cannot provide any definitive conclusions. Thus, there is an urgent need for prospective controlled trials in order assess the impact of TAP on survival and to compare different procedures.

Hans Eysenck was head of Psychology at the Maudsley Hospital during the heyday of Sir Aubrey Lewis. Eysenck established the Maudsley as a powerhouse of behaviourism. His clear and lucid style of writing, and his incisive mind, made him a formidable advocate. In 1952, he offered a challenge to the field of psychotherapy. In considering a number of outcome studies he

This section, IMAGES IN SLEEP MEDICINE, is intended to tap a relatively unique feature of sleep science: images that have great educational and conceptual content. These could be, for example, electroencephalograms, electromyograms, polysomnograms, portable devices, actigrams, scans including functional images, pathology specimens, brain slice preparations, fluorescent microscopy and other cutting edge techniques. The source may be human or nonhuman, but the clinical relevance should be clear. Illustrations must consist of clear and high-quality, blackand-white or color-digitized images. At this stage, videos can be submitted only for online publication. The message accompanying the picture may be a maximum of 500 words, with no more than 5 references. It is especially important not to try and make a case report out of these submissions, and detailed clinical (as contrasted to image) analysis should be avoided. The material should be submitted on the Sleep Medicine website (www.ees.elsevier.com/sleep). Images can be embedded within a text document such as Microsoft Word, a slide program such as Microsoft PowerPoint, or converted to Acrobat files. Authors should expect that the images will be available for use (with acknowledgement) to the general sleep community for teaching purposes, and so copyrighted/ patentable material should be avoided. In its final form, these images will be a freely available, searchable digital teaching image library. Comments regarding the images should be sent by e-mail to the section co-editors within a month of the publication date. These comments will be summarized and posted, if determined to be of educational content, with the original image on the journal’s web site, expected to be active for content soon. We hope this section will be enriched by the contributions of our colleagues who wish to offer stimulating opportunities for discussion and new insights in the field of sleep.

Orthostatic tremor (OT) is a rare, enigmatic, and poorly understood movement disorder triggered exclusively by standing, typically with the clinical complaint of unsteadiness and pathognomonic neurophysiologic characteristic of 13–18 Hz bursting EMG pattern, i.e., partially fused muscle contraction.1 Abnormal muscle tone control with stiffness, hyperactive startle responses, and limb spasms characterize stiff-person disorders (SPD), i.e., classic stiff-person syndrome (SPS), variant SPS, and progressive encephalomyelitis with rigidity and myoclonus.2 Autoimmunity accounts for SPD as a rule,2,3 and for OT as an exception.4,5 Progression of OT into SPS has never been reported.

Hemichorea-hemiballism associated with non-ketotic hyperglycaemia is a rare dyskinetic syndrome during uncontrolled or undiagnosed diabetes. We reported a 41-year-old man suffering from sudden choreodystonic movements and undiagnosed hyperglycaemia. We described a combination of several rare aspects, emphasising the importance of screening for diabetes as a cause of acute onset of hyperkinetic movement disorders.