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1.
Fluorescein sodium-guided resection of a cerebellar lymphoma: case report and literature review.
Franzini, A, Zekaj, E, Bona, A, Ciuffi, A, Porta, M, Servello, D
British journal of neurosurgery. 2023;(4):671-674
Abstract
We report on a patient, who underwent the resection of a cerebellar primary central nervous system lymphoma and was administered intraoperative fluorescein sodium to improve the visualization of the tumor and guide surgery. Low-dosage fluorescein was administered prior to opening the dura so to distinguish contrast-enhanced lymphomatous tissue from the surrounding unenhanced brain cerebellar parenchyma. Intraoperatively, the tumor was indistinguishable from cerebellar parenchyma under the white light, however, after the administration of low-dose intravenous fluorescein, it appeared brightly fluorescent under yellow light, and was safely resected. Our protocol of administration allowed for the sampling of the pathological tissue while at the same time avoiding neurological damage. The fluorescein-guided technique for the resection of primary central nervous system lymphomas has only been rarely described, as surgical excision of such tumors is rarely indicated. Starting from our case, we review and discuss the pertinent literature. Furthermore, an intraoperative video detail is provided.
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2.
Decreasing prevalence of retinopathy in childhood-onset type 1 diabetes over the last decade: A comparison of two cohorts diagnosed 10 years apart.
Salardi, S, Porta, M, Maltoni, G, Bassi, M, Minuto, N, D'Annunzio, G, Baltatescu, T, Ariaudo, M, Zucchini, S, Levantini, G, et al
Diabetes, obesity & metabolism. 2021;(8):1950-1955
Abstract
AIM: To ascertain whether the prevalence of retinopathy has declined over the last 2 decades in individuals with childhood-onset type 1 diabetes and whether this might be explained by changes in lifetime HbA1c. MATERIALS AND METHODS A multicentre, retrospective, observational study, comparing 128 subjects with diabetes onset in 2000-2003 assessed for retinopathy in 2016-2019, with a previous cohort of 115 individuals diagnosed in 1990-1993 and assessed for retinopathy in 2007-2009, was conducted. The two cohorts had both a similar diabetes duration and age at diagnosis. Retinal photographs were centrally graded. Lifetime HbA1c and its variability, estimated as the ratio between intrapersonal mean and standard deviation of HbA1c, were evaluated. RESULTS The prevalence of any retinopathy in the new and old cohort was 24.2% and 43.5% (P < .003), respectively, and that of severe retinopathy was 1.7% and 9.6% (P = .018). Lifetime HbA1c was lower in the new cohort (7.8% ± 0.8% vs. 8.1% ± 0.8%; P = .002) during all periods following the first 5 years after diagnosis. Patients without retinopathy in the two cohorts had similar levels of HbA1c. Compared with patients without retinopathy, those with retinopathy had higher lifetime HbA1c and long-term HbA1c variability. However, on multiple regression analysis, only lifetime HbA1c was independently associated with retinopathy (P = .0018). CONCLUSIONS The risk of developing retinopathy was nearly halved in children who developed type 1 diabetes in the new millennium compared with previous cohorts. These results confirm that maintaining the lowest possible levels of HbA1c throughout lifetime protects from diabetic retinopathy.
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3.
Changes in eating behavior after deep brain stimulation for anorexia nervosa. A case study.
Manuelli, M, Franzini, A, Galentino, R, Bidone, R, Dell'Osso, B, Porta, M, Servello, D, Cena, H
Eating and weight disorders : EWD. 2020;(5):1481-1486
Abstract
PURPOSE The purpose of this study was to evaluate changes in the nutritional status, body image concerns, and eating behaviors occurring in a patient who underwent deep brain stimulation (DBS) of the bed nucleus of the stria terminalis for treatment-refractory anorexia nervosa (AN). METHODS Bilateral DBS of the bed nucleus of the stria terminalis was performed in a 37-year-old woman affected by refractory AN. Pre- and post-surgical evaluations were conducted via an array of validated testing instruments, which took into account the weight variations, body image concerns, eating behavior, quality of life, and nutritional status. RESULTS Overall, eating behavior-, body image concern-, and nutritional status-related testing instruments demonstrated improvements starting from the first post-operative month. Normal body weight was restored after 4 months of stimulation. DISCUSSION Only a few cases of DBS for AN have been conducted to determine the efficacy of surgery based upon weight variation and psychometric scales for anxiety and affective disorders. In contrast, we have designed a comprehensive approach taking into account the most important aspects of this disease. This approach should be considered in future studies dealing with the neurosurgical treatment of AN.
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4.
Diabetic retinopathy, diabetic macular edema, and cardiovascular risk: the importance of a long-term perspective and a multidisciplinary approach to optimal intravitreal therapy.
Bandello, F, Toni, D, Porta, M, Varano, M
Acta diabetologica. 2020;(5):513-526
Abstract
Diabetic retinopathy (DR), diabetic macular edema (DME), and cardiovascular disease (CVD) resulting from vascular damage from persistently elevated blood glucose levels are among the serious secondary pathologies associated with long-standing diabetes mellitus. The established link between DR and CVD suggests the need for appropriate and early management of patients with diabetes to minimize CV risk. This is of particular importance in patients with recent, or a history of, major CV events. Early management of DR is a complex task that requires comprehensive evaluation and a multidisciplinary approach to manage complications, risk factors, and interactions between different aspects of the disease. Anti-vascular endothelial growth factor (VEGF) agents have become an important therapeutic modality in ophthalmology. However, their use is contraindicated in patients with DR and/or DME with a CV event in the previous 3 months. In patients with DME, corticosteroids target the multifaceted inflammatory pathways involved in the pathogenesis of DR, with a broader spectrum of action than anti-VEGF agents. In this context, recent guidelines suggest the use of corticosteroids, and in particular dexamethasone intravitreal implant, as a well-tolerated and efficacious first-line treatment in patients with high CV risk, such as a history of or recent major CV events. This review focuses on the subset of diabetic patients with a prior CV event, DR, and DME and discusses the need for a holistic approach in evaluating the optimal therapeutic choice for the care of the individual patient, supported by real-world clinical experience on long-term dexamethasone intravitreal implant therapy.
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5.
Fundamental principles of an effective diabetic retinopathy screening program.
Lanzetta, P, Sarao, V, Scanlon, PH, Barratt, J, Porta, M, Bandello, F, Loewenstein, A, ,
Acta diabetologica. 2020;(7):785-798
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Abstract
BACKGROUND Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults worldwide. Early detection and treatment are necessary to forestall vision loss from DR. METHODS A working group of ophthalmic and diabetes experts was established to develop a consensus on the key principles of an effective DR screening program. Recommendations are based on analysis of a structured literature review. RESULTS The recommendations for implementing an effective DR screening program are: (1) Examination methods must be suitable for the screening region, and DR classification/grading systems must be systematic and uniformly applied. Two-field retinal imaging is sufficient for DR screening and is preferable to seven-field imaging, and referable DR should be well defined and reliably identifiable by qualified screening staff; (2) in many countries/regions, screening can and should take place outside the ophthalmology clinic; (3) screening staff should be accredited and show evidence of ongoing training; (4) screening programs should adhere to relevant national quality assurance standards; (5) studies that use uniform definitions of risk to determine optimum risk-based screening intervals are required; (6) technology infrastructure should be in place to ensure that high-quality images can be stored securely to protect patient information; (7) although screening for diabetic macular edema (DME) in conjunction with DR evaluations may have merit, there is currently insufficient evidence to support implementation of programs solely for DME screening. CONCLUSION Use of these recommendations may yield more effective DR screening programs that reduce the risk of vision loss worldwide.
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Self-management education may improve blood pressure in people with type 2 diabetes. A randomized controlled clinical trial.
Trento, M, Fornengo, P, Amione, C, Salassa, M, Barutta, F, Gruden, G, Mazzeo, A, Merlo, S, Chiesa, M, Cavallo, F, et al
Nutrition, metabolism, and cardiovascular diseases : NMCD. 2020;(11):1973-1979
Abstract
BACKGROUND AND AIMS Diabetes is a suitable model to evaluate intervention programmes aimed at chronic diseases, because of its well-defined and measurable process and outcome indicators. In this study, we aimed at investigating the effects of group based self-management education on clinical and psychological variables in type 2 diabetes. METHODS AND RESULTS Four-year randomized controlled clinical trial (ISRCTN14558376) comparing Group Care and traditional one-to-one care. Clinical and psychological variables were monitored at baseline, 2 and 4 years. Although differences between groups appear to be non-significant at univariate analysis, body weight, BMI and HbA1c, systolic and diastolic blood pressure improved in the patients followed by Group Care but not among Controls. Prescription of lipid-lowering and anti-hypertensive agents did not change among the patients on Group Care, whereas anti-hypertensives were stepped up among Controls without improving their blood pressure. Multivariable analysis suggests that blood pressure improvement among patients on Group Care was independent of BMI, duration of diabetes and antihypertensive medication, suggesting a direct effect of education, presumably by increasing adherence. The "Powerful Others" dimension of the Locus of Control worsened and fear of complications decreased among Controls. CONCLUSIONS The results confirm that a multidisciplinary structured group educational approach improves blood pressure, presumably through better adherence to healthy lifestyle and medication, in people with type 2 diabetes. CLINICAL TRIAL REGISTRATION NUMBER ISRCTN14558376.
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7.
Intravitreal anti-VEGF agents and cardiovascular risk.
Porta, M, Striglia, E
Internal and emergency medicine. 2020;(2):199-210
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Abstract
Antagonists of Vascular Endothelial Growth Factor (Anti-VEGF) are widely administered by intravitreal injection for the treatment of ocular pathologies such as Age-related Macular Degeneration, Diabetic Macular Edema, Proliferative Diabetic Retinopathy and occlusion of retinal vessels. Anti-VEGF agents, in particular bevacizumab, were introduced in oncology to inhibit tumor-induced angiogenesis feeding neoplastic tissues. Subsequently, other specific agents were developed for intraocular administration. Whereas systemic administration of anti-VEGF agents in oncology is burdened by increased risk of arterial hypertension and embolism, agents administered for ophthalmic indications are delivered locally into the eye globe in much smaller quantities. Nevertheless, clinical observations have raised the possibility that, even in these conditions, anti-VEGF agents may increase cardiovascular risk in patients who, being elderly and/or diabetic, are intrinsically prone to such events. This paper aims at reviewing the current knowledge on VEGF and its pharmacologic antagonists from mechanistic and side effect points of view, with specific reference to patients with sight-threatening conditions. Internists should be aware of the need to collaborate with ophthalmologists and pharmacovigilance operators to define as best as possible the risk/benefit balance of intravitreal agents in patients who might lose their sight if left untreated, or increase their risk of suffering a cardiovascular event if treated.
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8.
Vision-related quality of life and locus of control in type 1 diabetes: a multicenter observational study.
Trento, M, Charrier, L, Cavallo, F, Bertello, S, Oleandri, S, Donati, MC, Rizzo, S, Virgili, G, Picca, G, Bandello, F, et al
Acta diabetologica. 2019;(11):1209-1216
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AIMS: Diabetic retinopathy remains asymptomatic until its late stages but remains a leading cause of vision impairment and blindness. We studied quality of life and the ability to deal with the discomfort deriving from the presence of a chronic disease in patients with type 1 diabetes and different stages of retinopathy. METHODS Multicenter collaborative observational study involving nine centers screening for retinopathy in different areas of Italy. The National Eye Institute 25-item visual functioning questionnaire and the locus of control tool were administered to 449 people with type 1 diabetes between February 2016 and March 2018. Socio-demographic and clinical data were collected. RESULTS On multivariable analysis, severe retinopathy is associated with worse scores for general vision, ocular pain, near vision activities, distance vision activities, driving, color vision, peripheral vision and lower values of internal control, independently of visual acuity. Women had a perception of worse general health, distance vision activities and driving, and lower internal control and trust in others. Worse scores for visual-specific social functioning, visual-specific mental health, visual-specific role difficulties, visual-specific dependency and peripheral vision were associated with higher HbA1c levels. Fatalism increased with rising HbA1c levels. CONCLUSIONS These results confirm that a gap exists between patients' knowledge and expectations on retinopathy and providers' expertise and assumptions. To bridge this gap, patient-centered education and engaging approaches may be more effective than simple information given during consultations.
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Effects of Topically Administered Neuroprotective Drugs in Early Stages of Diabetic Retinopathy: Results of the EUROCONDOR Clinical Trial.
Simó, R, Hernández, C, Porta, M, Bandello, F, Grauslund, J, Harding, SP, Aldington, SJ, Egan, C, Frydkjaer-Olsen, U, García-Arumí, J, et al
Diabetes. 2019;(2):457-463
Abstract
The primary objective of this study was to assess whether the topical administration of two neuroprotective drugs (brimonidine and somatostatin) could prevent or arrest retinal neurodysfunction in patients with type 2 diabetes. For this purpose, adults aged between 45 and 75 years with a diabetes duration ≥5 years and an Early Treatment of Diabetic Retinopathy Study (ETDRS) level of ≤35 were randomly assigned to one of three arms: placebo, somatostatin, or brimonidine. The primary outcome was the change in implicit time (IT) assessed by multifocal electroretinography between baseline and at the end of follow-up (96 weeks). There were 449 eligible patients allocated to brimonidine (n = 152), somatostatin (n = 145), or placebo (n = 152). When the primary end point was evaluated in the whole population, we did not find any neuroprotective effect of brimonidine or somatostatin. However, in the subset of patients (34.7%) with preexisting retinal neurodysfunction, IT worsened in the placebo group (P < 0.001) but remained unchanged in the brimonidine and somatostatin groups. In conclusion, the topical administration of the selected neuroprotective agents appears useful in preventing the worsening of preexisting retinal neurodysfunction. This finding points to screening retinal neurodysfunction as a critical issue to identify a subset of patients in whom neuroprotective treatment might be of benefit.
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Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA).
Coccolini, F, Ceresoli, M, Kluger, Y, Kirkpatrick, A, Montori, G, Salvetti, F, Fugazzola, P, Tomasoni, M, Sartelli, M, Ansaloni, L, et al
Injury. 2019;(1):160-166
Abstract
INTRODUCTION No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. MATERIAL AND METHODS A prospective analysis of adult patients enrolled in the IROA. RESULTS Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. CONCLUSION Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.