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Biomedical subjects

M Caldarelli

Publications and source records attributed to M Caldarelli.

At least 37 records · Page 2Linked to original sources
PubMed2002

Does locomotion improve the cognitive profile of children with meningomyelocele?

OBJECTIVE: This study was conducted to test the hypothesis that locomotion can improve cognitive development in a paediatric population with meningomyelocele (MMC) and hydrocephalus. METHODS: Twenty-nine children with MMC and shunted hydrocephalus were studied. All had motor impairment, but after physiotherapy and training walking was possible in 23 of them (5 autonomously and 18 with an aid), while 6 had recourse to a wheelchair. In all 23 cases neuroimaging (TC scan and/or MRI) was performed to obtain data on the sequelae of perinatal lesions, alterations of the corpus callosum, and the presence or absence of cortical abnormalities and ventricular dilatation. All subjects underwent a neuropsychological assessment including the Wechsler Pre-school and Primary Scale for Infants (WIPPSI) and the Wechsler Intelligence Scale for Children Revisited (WISC-R). Statistical analysis was carried out with the ANOVA test. RESULTS: Even though global I.Q. in these MMC children was within the normal range, the characteristic splitting between verbal I.Q. (VIQ) and performance I.Q. (PIQ) was observed, but the most interesting observation was a significant performance-related difference (P=0.044 and P=0.012) between ambulatory patients (both with and without aids) and those who were dependent on wheelchairs (PIQ: 83-85 vs 63).

Adolescent↗
PubMed2002

Surgical treatment of chronic subdural hygromas in infants and children.

BACKGROUND: Extra-axial chronic fluid collections are pathological conditions occurring more frequently in the paediatric age, particularly in children less than two-year-old. Although recognised for many years and repeatedly reported in the literature, some aspects of their treatment are still under debate. This review of the management of chronic subdural collections is based on our experience of 72 cases treated between January 1984 and December 2000. METHOD: Patients were divided into four groups according to aetiology. Thirty-four cases (47%) occurred following various surgical procedures; 14 cases (20%) occurred as complications of leptomeningeal infections; 13 cases (18%) were post-traumatic, whereas no obvious aetiology could be detected in the last 11 cases (15%). The collections were unilateral in 34 patients (47%) and bilateral in the other 38 (53%). FINDINGS: Thirty-five patients (48%) were treated by means of a temporary subdural external drainage (SED) (for a total of 38 SED procedures), which was maintained for a mean of 5.8 (+/-3.4) days; it was effective in 26 cases, whereas in the other 9 it was necessary to perform a subdural-peritoneostomy (SPS). Three of these 38 SEDs were complicated by infection. In one more child the external drainage was complicated by a chronic subdural haematoma. A SPS was performed in 44 cases (61%), 9 being failed external drainages. Only in 16 (38%) of these 44 patients the SPS was removed after an average of 27.0 (+/-16.6) months. Three patients (4%) were treated by craniotomy and resection of the neomembranes lining the subdural fluid collection. Obstruction of the SPS occurred in 6 children, infection in 4. Good results were obtained with either external or internal drainage. In fact post-operative neuroradiological investigation disclosed in all the cases complete or almost complete cerebral re-expansion; also the clinical outcome was generally very good, although largely dependent upon the basic clinical condition. Unilateral subdural-peritoneal and/or external drainage was effective also in case of bilateral collections. Only 2 patients required temporary bilateral external drainage.

Adolescent↗
PubMed2002

Solid-supported reagents for multi-step organic synthesis: preparation and application.

Since the early days of combinatorial chemistry solid-phase organic synthesis has been the method of choice for the production of large libraries. Solution-phase synthesis is again gaining importance especially for the synthesis of parallel arrays of smaller, focussed libraries containing single compounds with high degrees of purity. In the field of solution-phase library generation, the use of solid-supported reagents, catalysts and scavengers is emerging as a leading strategy, combining the advantages of both solid-phase organic synthesis (e.g. allowing the employment of an excess of reagent without the need for additional purification steps) and solution-phase chemistry (e.g. the ease of monitoring the progress of the reactions by applying LC-MS, TLC or standard NMR techniques). An account of some of the most recent advances in this area of research will be presented.

Combinatorial Chemistry Techniques↗
PubMed2001

Intra-axial dermoid/epidermoid tumors of the brainstem in children.

BACKGROUND: Epidermoid and dermoid cysts are rare intracranial space-occupying lesions, which account for about 1% of all intracranial tumors; they are even rarer in the pediatric age group. Among the various locations, that inside the brain stem is quite exceptional (only 12 cases reported to date in the literature). We report two additional cases occurring in children, underlining their clinical characteristics, the difficulties faced in the diagnostic work-up, and the surgical treatment adopted (which consisted of removal of the cyst contents and partial resection of the cyst membrane, because of its adherence to the surrounding nervous and vascular structures). METHODS: We report two cases of intraaxial dermoid/epidermoid cysts observed within the last 5 years. Both patients complained of cervico-nuchal pain, with a remittent/intermittent character in one of them; this patient also exhibited transient 6th and 7th cranial nerve deficit. One lesion was approached through the floor of the fourth ventricle, the second one through the ventrolateral aspect of the brainstem. RESULTS: Subtotal tumor resection was achieved in both cases. Both patients had a smooth postoperative course without permanent neurological deficits. In the first patient residual tumor remains stable on follow-up MRI. In the second one, early tumor regrowth necessitated a second operation, after which the residual tumor has remained stable. CONCLUSIONS: Based on our experience we suggest that a cautious surgical approach ("conservative" resection) to these lesions is the best choice. In fact, attempts at radical removal carry unacceptably high morbidity and mortality rates.

Adolescent↗
PubMed2001

Surgical treatment of moyamoya disease in pediatric age.

BACKGROUND: Moyamoya is a progressive occlusive cerebrovascular disease which affects the distal internal carotid artery and its main branches, and is characterized, from a clinical point of view, by a variety of ischemic manifestations ranging from transient ischemic attacks (TIA) to stroke. Although considered until recently as almost specific of Japanese population, it can also affect individuals of different origin, and there is an increasing interest for this rare disease in Western medical literature. Nonetheless papers dealing with moyamoya disease in pediatric age are still very rare and almost exclusively limited to isolated case reports. These considerations prompted us to review our experience with the diagnosis and treatment of such unusual disease. METHODS: Nine children (seven months to nine years of age) presented with clinical manifestations of occlusive cerebrovascular disease (TIAs or stroke), epilepsy, and/or psychomotor retardation. Neuroradiological investigation, and in particular cerebral angiography, demonstrated the classical pattern of moyamoya disease. Eight of these children underwent cerebral revascularization utilizing the encephalomyosynangiosis (EMS) technique, with a total of 14 operations (six on both sides, two on one side). RESULTS: There was no mortality neither major morbidity related to surgery. One patient with renovascular hypertension, died at home approximately six months after a successful operation, probably from cerebral hemorrhage. In all the cases postoperative angiography revealed a marked improvement in cerebral circulation. However, in spite of the apparently normalized cerebral blood flow, clinical manifestations were affected less significantly. In fact, there was only minimal if any improvement in children operated on with an already established hemiplegia; whereas improvement in motor ability was obtained in those presenting with hemiparesis or TIAs, as well as in epilepsy and psychomotor retardation. CONCLUSIONS: On the grounds of our results we conclude that cerebral revascularization (by means of a simple operation like the EMS) in children with moyamoya disease is worthwhile, provided that the operation be performed before irreversible cerebral damage is established; however, even under these circumstances the operation can at least stop the progression of the disease.

Age Factors↗
PubMed2000

Phenyl sulfur mustard derivatives of distamycin A.

The design, synthesis, and cytotoxic activity of novel benzoyl and cinnamoyl sulfur mustard derivatives of distamycin A are described and structure activity relationships are discussed. These sulfur mustards are more potent cytotoxics than corresponding nitrogen mustards in spite of the lower alkylating power, while their sulfoxide analogues are substantially inactive. Cinnamoyl sulfur mustard derivative (7) proved to be one of the most active distamycin-derived cytotoxics, about 1000 times more potent than melphalan.

Distamycins↗
PubMed2000

Cytotoxic halogenoacrylic derivatives of distamycin A.

The design, synthesis, in vitro and in vivo activities of a series of halogenoacrylic derivatives of distamycin A are described. The structure-activity relationships indicate a key role of the reactivity of alpha-halogenoacrylic moiety. The reactivity and the putative alkylating mechanism of these compounds are different from those of the nitrogen mustards and possibly based on a Michael type reaction. This supports the hypothesis that these compounds represent a class of minor groove binders mechanistically different from tallimustine.

Animals↗
PubMed2000

Cytotoxic alpha-bromoacrylic derivatives of distamycin analogues modified at the amidino moiety.

The design, synthesis, in vitro and in vivo activities of novel alpha-bromoacrylic derivatives of distamycin A, modified at the amidino moiety by the replacement with basic or non-basic groups are reported. In spite of the relevance of these modifications of distamycin frame, the new derivatives are potent cytotoxics. The presence of the amidino moiety, is, therefore; not an absolute requirement for the activity. In particular due to a favorable myelotoxicity/cytotoxicity ratio, guanidino derivative PNU 166196 was selected for clinical development.

Amidines↗
PubMed2000

Preemptive analgesia with tramadol and fentanyl in pediatric neurosurgery.

Preemptive analgesia is based on administration of an analgesic before a painful stimulus generates, so as to prevent the subsequent rebound mechanism. Tissue injury results in disruption of the processing mechanisms of noxious stimuli afferent to the CNS (central nervous system) by way of an increase of inputs in the spinal cord. These reactions may be reduced by the administration of opioids. Few studies on preemptive analgesia with opioids in children are available, and none of them is concerned with pediatric neurosurgery. Tramadol and fentanyl are synthetic opioids which are relatively new and act through the activation of pain-inhibitory mechanisms. We conducted a randomized, prospective trial on the preemptive effects in children of these two analgesic drugs, administered according to three different protocols: tramadol as a bolus (1 mg/kg); tramadol by continuous infusion (150 microg/kg per h); fentanyl by continuous infusion (2 microg/kg per h). In all, 42 children undergoing major neurosurgical operations were enrolled in the study, 14 in each treatment group. Each treatment was started at the induction of general anesthesia and continued throughout the entire duration of the operation. The postoperative pain evaluation was conducted in the Pediatric Intensive Care Unit at the end of the surgical operations and involved comparison of any changes in behavioral (AFS scale and CHEOPS score) and hemodynamic (heart rate, respiratory rate, systolic and diastolic arterial pressure, oxygen saturation, O(2) and CO(2) partial pressure) parameters. Only 2 children, both in group A, needed further drug administration postoperatively. No significant side effects were noticed in any of the three groups, except that in group A there was a higher incidence of nausea and vomiting. Tramadol efficacy seems to be better when it is administered in continuous infusion; this treatment modality also leads to fewer adverse effects. Fentanyl, in contrast, proved to be superior to tramadol in the treatment of postoperative pain. In conclusion, preemptive analgesia is a valid technique for the treatment of acute pain in children undergoing major neurosurgical operations.

Adolescent↗
PubMed1998

Management of recurrent craniopharyngioma.

Although histologically benign, craniopharyngioma can regrow either from macroscopic remnants of the tumour left behind at operation, or even after an apparently gross total removal. Recurrence rates vary significantly in the literature, depending on the efficacy of surgical treatment and also on the growth potential of the tumour itself. The main factor influencing tumour regrowth is obviously the extent of surgical resection, as total removal carries a much lesser risk of recurrence compared to subtotal or partial resections (although in such cases radiation therapy can lower this risk significantly). Other factors involved are the duration of follow-up and patient's age at operation, as children tend to relapse more frequently than adults. Even in the "microsurgery" era, characterized by high percentages of total resections, recurrences remain high and continue to represent a major problem of craniopharyngioma treatment. Twenty-seven children and adolescents were operated on for craniopharyngioma at the Department of Neurosurgery, Section of Pediatric Neurosurgery, Catholic University Medical School, Rome between June 1985 and June 1997. Total tumour resection was achieved in 18 cases, subtotal in 7 and partial in 2 instances. One patient died post-operatively. Post-operative neuroradiological investigations confirmed the operative findings, although 3 children with an apparently gross total removal showed a residual non-enhancing calcium fleck adherent to the hypothalamus (which remained stable at the following examinations). Three of the 9 patients with less than total removal underwent post-operative radiation therapy. Out of the 26 surviving patients 6 presented a recurrence of their craniopharyngioma, 2 after an apparently gross total removal and 4 after a subtotal or partial resection (one of them had received radiation therapy). The diagnosis was merely neuroradiological in 5 cases, as only one child presented a clinical picture suggestive of tumour regrowth. Surgery was the first therapeutic option in all the cases. Total tumour resection was accomplished in 3 cases, subtotal in 2 and partial in the last one. One child died post-operatively. Four of the 5 survivors received radiation therapy. All the patients are presently alive and stable (mean follow-up: 5.6 yrs). The authors conclude that surgery should be the first therapeutic option in case of recurrent craniopharyngioma and that radiation therapy should also be considered but only as adjuvant therapy.

Adolescent↗
PubMed1998

Treatment of hydromyelia in spina bifida.

BACKGROUND: Cavitation of the spinal cord (hydrosyringomyelia) seems to be common in spina bifida patients, although the overall clinical and radiological incidence has very rarely been analyzed. The real incidence of the condition is, in fact, difficult to assess as patients with this complication may remain relatively asymptomatic. The mechanisms accounting for the occurrence of hydrosyringomyelia in myelodysplasia are still a subject of debate. Similarly, the indications for the surgical treatment are still to be defined and its results to be assessed. METHODS: In this study, 142 patients with spina bifida were screened with magnetic resonance imaging (MRI) to determine the incidence of hydromyelia. Thirty-two patients presented a cavitating lesion on MRIs of which 18 were not a cause of symptoms and 14 were. Clinical characteristics of the lesions and their correlation to the radiological picture were analyzed. All the symptomatic children underwent surgical treatment. Outcomes were evaluated and correlated also with the MRI findings. RESULTS: A correlation between the presence of symptomatology and the extension and/or dilation of the hydromyelia was observed. A significant relationship between the presence of symptoms and adequate control of associated hydrocephalus was also noted. No correlation was observed between the presence of hydromyelia and the level of the myelomeningocele or the degree of ventricular dilation in those cases that presented with hydrocephalus. The mean age at hydromyelia diagnosis for all patients affected was 3.9 years and, in particular, 4 years for those patients who presented with symptoms. A total of 15 operations were performed in the 14 symptomatic patients. Seven direct procedures were carried out to drain the hydromyelia: five hydroperitoneal shunt insertions and two hydrosubarachnoid shunting procedures. Eight indirect treatments were performed to eliminate the filling mechanism of the hydromyelia: five posterior fossa decompressions, two ventriculoperitoneal shunt revisions, and one spinal cord untethering procedure with terminal syringostomy. All patients improved postoperatively, except one who remained clinically stable at follow-up. This patient had undergone a posterior fossa decompression followed by a hydrosubarachnoid shunting procedure. CONCLUSIONS: The incidence of syringohydromyelia is actually higher than that reported in the literature, although not all lesions are symptomatic. The radiological picture may be helpful in planning a more careful follow-up program for patients theoretically at risk for neurologic deterioration. Surgical treatment is possible with good results in the majority of cases and should be carried out as soon as possible before further deterioration occurs. Not all symptoms respond equally to treatment. Generally, improvement of clinical status correlates with a reduction in size of the hydromyelic cavity on MRI.

Child↗
PubMed1997

Combined management of intracranial vascular malformations in children.

UNLABELLED: We have reviewed 39 cases of intracranial vascular malformations, observed in the Section of Paediatric Neurosurgery of the Catholic University of Rome between 1980 and 1995 (age 1-15 years). Diagnosis was of parenchimal AVM in 26 cases, in 7 cases of AVM of the Galen region, in 5 cases of dural AVM and in 1 case of venous angioma. RESULTS AND CONCLUSIONS: Haemorrhage was the prevalent clinical onset in patients with parenchimal AVMs (57.7% of cases). Only one patient with a Galen region AVM presented cardiovascular symptoms, while 2/5 children observed for a dural AVM complained a congestive heart failure. Total surgical excision was performed in 17 of the 26 patients with parenchimal AVMs; moreover surgery was combined with preoperative endovascular embolization in 2 cases and with radiosurgery in 1 patient; we think that surgery is still the treatment of choice in patients with parenchimal AVMs. Endovascular treatment and radiosurgery have mainly an adjuvant role; nevertheless we agree that a preoperative endovascular management of parenchimal AVMs reduces the surgical risk, especially in cases of huge AVMs or AVMs localized in eloquent areas of the brain. Radiosurgery may be an alternative choice for complex or deeply sited AVMs; however in most cases, a combination with surgery or endovascular treatment is necessary to reduce the "target" size. AVM embolization was the only treatment in 2 of the 6 cases of dural AVMs; dural AVM embolization was combined with surgery in 1 case. Endovascular AVM exclusion is the treatment of choice in these patients. Surgery may be combined with endovascular treatment in case of a partial persistence of the AVM, or if signs of revascularization are present on control angiography. A conservative management is justified in patients with carotido-cavernous fistulae; in fact a complete spontaneous thrombosis is very frequent in these cases. A high rate of cardiovascular symptoms is reported in patients with Galen region AVMs diagnosed in the 1st year of life, but only 1 of our patients complained of congestive cardiac symptoms. Surgical treatment of Galen region AVMs is associated with a high morbidity and mortality. Actually a transarterial embolization of afferent vessels represents the treatment of choice in these patients; it can be combined with transvenous approach in case of complex AVMs and/or a non complete AVM exclusion.

Adolescent↗
PubMed1996

Shunt complications in the first postoperative year in children with meningomyelocele.

The authors analyze the incidence of early mechanical and infective CSF shunt complications and various factors that might be correlated with the incidence in a series of 170 children affected by hydrocephalus and meningomyelocele (MM), with the aim of the finding to this specific risk factors related to this particular type of hydrocephalus. Factors investigated for correlation with CSF shunt malfunction are the following: level of spinal malformation, age of the patient at MM repair, age at diagnosis of hydrocephalus, degree of ventricular dilatation, age at shunt implantation, modality of the surgical procedure, characteristics of CSF at operation. In the first postoperative year following CSF shunting, 45.9% of the patients presented one shunt malfunction, three-quarters of which were due to mechanical causes, and one quarter to infection. Age of the patient at diagnosis of hydrocephalus and at CSF shunt operation did not significantly influence shunt patency, nor did the surgical modality (programmed vs emergency procedure). On the other hand, MM level did influence the outcome of CSF shunting: a higher percentage of malfunctions (and in particular of infective complications) was observed among the patients with "high level" MMs than in the group with more caudal location of the spinal defect. Similarly, the degree of ventricular dilatation correlated with the incidence of complications (more severe ventricular dilatation was associated with the highest incidence of complications). The order in which MM repair and CSF shunting were carried out and the age of the patients at MM repair did not affect the occurrence of mechanical complications, whereas they had a significant effect on the incidence of infective complications. In fact, the rate of overall complications, and of infective complications in particular, was proportional the age at MM repair. Furthermore, the group of children who underwent to MM repair and CSF shunting simultaneously scored the lowest percentage of complications, although these were mainly infections; the highest incidence of complications (and in particular of infective ones) was observed in the children who underwent CSF shunting first. The most striking correlation, however, was found with the characteristics of CSF. While normal CSF values correlated with an overall incidence of complications of 39.2%, abnormal CSF values were correlated with a rate of complications of 90.9%; in particular, the rates of infective complications were 2.7% and 77.3%, respectively. On the grounds of these observations a protocol is proposed of temporary CSF external drainage in children requiring prompt relief of increased intracranial pressure but at risk for the presence of a leaking spinal defect or of a MM left unrepaired for more than 48 h.

Cerebrospinal Fluid Shunts↗