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OBJECTIVES: The laparoscopic trans-abdominal preperitoneal (TAPP) approach to inguinal hernia repair is well documented as an excellent choice in numerous studies, especially when conducted by an experienced surgeon. Its full list of specific indications is still under debate. Generally, the repair of scrotal hernias demands a higher level of experience on the part of the surgeon, irrespective of the applied surgical technique. In this report, we evaluate our preliminary experience of TAPP laparoscopic repair for inguinoscrotal hernias in young patients in a Community Hospital setting, focusing on the feasibility of the technique and the incidence of complications. MATERIALS AND METHODS: Between January 2008 and January 2009 a total of ten consecutive young patients at the "Civil Hospital" in Vittorio Veneto (TV), underwent TAPP laparoscopic repair of bilateral inguinoscrotal hernias. RESULTS: The overall mean operative time was 65 (+/-15) min. All procedures were performed on a day surgery basis. There were no conversions to open repair, no mortality/morbidity or relapsing hernias. The mean follow-up was 14 (+/-2) months. No patients reported severe pain at 10 days, There were no reports of night pain at 30 days. All patients had a return to physical-work capacity within 14 days. All patients were completely satisfied at the 3-month follow up. CONCLUSIONS: Analysis of the short-term post-operative outcomes of our experience enabled us to conclude that, in the proper setting, TAPP can be performed for inguinoscrotal hernia repair with an efficiency comparable to that of normal inguinal hernia repair.

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Recombinant FSH (r-FSH) used for ovarian stimulation can currently be self-administered either by a conventional syringe or by a pen device. This randomized controlled trial compares the efficacy and convenience of a new, more sophisticated and fully automated injection device (Softinject(trade mark)) with the conventional syringe for r-FSH self-administration. A total of 300 women needing ovarian stimulation for IVF/intracytoplasmic sperm injection were randomized to the automated injector or the conventional syringe group. Patients of both groups had ovarian stimulation with follitropin alpha after pituitary desensitization with a gonadotrophin-releasing hormone agonist. State anxiety score, overall pain score and pregnancy rate were chosen as the main outcome measures. Patients in the automated injector group showed lower state anxiety (P < 0.01) and overall pain (P < 0.01) scores and a comparable pregnancy rate per started cycle as compared with the conventional syringe group. They needed lower doses of r-FSH (P < 0.05) and their stimulation was shorter (P < 0.05). It is concluded that the use of a fully automated injector for r-FSH self-administration reduces pain and stress as compared with the conventional syringe. This device can be used for any subcutaneously administered drug employed in ovarian stimulation.

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OBJECTIVE: To evaluate motor cortex excitability changes by transcranial magnetic stimulation (TMS) following repetitive muscle contractions in patients with multiple sclerosis (MS); to state whether a typical pattern of post-exercise motor evoked potentials (MEPs) is related to clinical fatigue in MS. METHODS: In 41 patients with definite MS (32 with fatigue and 9 without fatigue according to Fatigue Severity Scale) and 13 controls, MEPs were recorded at rest: at baseline condition, following repetitive contractions until fatigue, and after fatigue, to evaluate post-exercise MEP facilitation (PEF) and depression (PED). RESULTS: After exercise, MEP amplitude significantly increased both in patients and controls (PEF). When fatigue set in, MEP amplitude was significantly reduced in normal subjects (PED), but not in patients. Post-exercise MEP findings were similar both in patients with and without fatigue. CONCLUSIONS: Our findings suggest an intracortical motor dysfunction following a voluntary contraction in MS patients, possibly due to failure of depression of facilitatory cortical circuits, or alternatively of inhibitory mechanisms.

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Benign adult familial myoclonic epilepsy (BAFME) has been mapped to chromosome 8q24; however, genetic heterogeneity has been recently suggested. The authors report a clinical and electrophysiologic study of two Italian BAFME families showing linkage to chromosome 2p11.1-q12.2. Their report supports the evidence of non-Japanese families with BAFME and suggests a possible allelism with the recently described autosomal dominant cortical myoclonus and epilepsy syndrome.

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OBJECTIVES: Pudendal nerve somatosensory evoked potentials (SEPs), the bulbocavernosus (BC) reflex, and BC perineal motor evoked potentials after transcranial magnetic cortical stimulation were performed in patients with primary premature ejaculation to investigate the somatic sensory and motor function of the genital area. METHODS: Fourteen patients with primary premature ejaculation underwent psychological counseling, urologic physical examination, transrectal ultrasound examination, laboratory testing, and the Stamey test. The spinal and cortical pudendal nerve SEPs were performed by dorsal nerve stimulation at the penile shaft (DN-SEPs) in all patients and at the glans penis (GP-SEPs) in 3 of them. The BC reflex was obtained by stimulating the base of the penis. RESULTS: The mean sensory threshold did not significantly differ between the patients and normal subjects. Cortical DN-SEPs were normal in all patients. The sensory central conduction time, calculated in 6 patients, was normal. The mean cortical DN-SEP amplitude was significantly smaller in patients than in controls. In 3 patients and in 3 controls who underwent both DN-SEP and GP-SEP testing, the glans penis sensory threshold was lower than the dorsal nerve threshold and the cortical GP-SEP latency was longer than the cortical DN-SEP latency. The BC reflex was normal in most patients. The BC motor evoked potentials were normal in all patients, but one. CONCLUSIONS: We did not confirm either a faster conduction along the pudendal sensory pathway or a greater cortical representation of the sensory stimuli from the genital area in our patients. Moreover, we did not confirm hyperexcitability of the BC reflex in them. Our results suggest that the electrophysiologic approach is probably not sufficient to clarify the causes of primary premature ejaculation. A more integrated investigation could allow better results in this field.

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OBJECTIVE: To explore motor control reorganization in a 40-year-old, left-handed patient with perinatally acquired mirror movements. METHODS: We performed simultaneous bilateral recordings of motor evoked potentials (MEPs) following focal transcranial magnetic stimulation (fTMS) and of central silent period (cSP) during unilateral voluntary contraction in abductor pollicis brevis (APB) and abductor digiti minimi (ADM) muscles. RESULTS: For both muscles the MEP study showed bilateral fast-conducting corticospinal projections from the right undamaged hemisphere, and residual contralateral projections from the left hemisphere. The cSP findings differed in the two muscles: the mirror phenomenon was bilateral in the ADM, but present only on the right side in the APB muscles; the mirror activity of right ADM and APB muscles was inhibited only by fTMS of the ipsilateral right motor cortex; the mirror phenomenon in the left ADM muscle was inhibited only by fTMS of the contralateral right motor cortex. CONCLUSIONS: Mirror movements of right APB and ADM muscles were sustained by the ipsilateral connections from the undamaged motor cortex, while the mirror phenomenon in the left ADM muscle could be explained by hypothesizing a bilateral activation of motor cortices. This previously unreported electrophysiological picture demonstrates that different patterns of motor control may realize after perinatal cerebral lesions, even in different distal muscles of the same patient.

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We have studied motor, somatosensory, brainstem auditory and visual evoked potentials in two patients with ML III without overt neurologic symptoms. Both our patients showed abnormal central motor functions upon magnetic cortical stimulation; in addition, in one of them, we observed a decreased conduction velocity of the nervous impulse in the central tract of the upper limb somatosensory pathway, from the cervical spinal cord to sensory cortex. Our results suggest that central motor pathways are affected in both children and also that the central somatosensory system is involved in one of them. We propose that the electrophysiological techniques might be of help to detect, locate and monitor minimal neurological lesions of mild lysosomal disorders like ML III.

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Pudendal nerve somatosensory evoked potentials (PN-SSEPs) were recorded in 21 healthy children (age range: 3.3-13.3 years). The dorsal nerve of the penis/clitoris was stimulated and SSEPs were recorded at spinal L1-D12 and at cortical Cz'-Fz. Morphology, latency and amplitude of the cortical SSEPs were evaluated. A cortical response was obtained in all but two subjects. Cortical SSEPs were broader and less defined in shape in the youngest subjects. There was a progressive shortening of the latency of the P and N components during growth. Spinal responses were obtained only in 6 cases. Nine subjects also underwent tibial nerve stimulation. Pudendal and tibial SSEPs differed in their degree of maturation.

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The H-reflex recovery curve of the lower limb is considered a useful test for the diagnosis of spasticity, and recently the reciprocal inhibition of the H-reflex has proven to be abnormal in patients affected with spasticity. We studied the H-reflex recovery curve and the reciprocal inhibition of the H-reflex in the upper limb of a group of 33 patients with different degrees of spasticity secondary to stroke. Results were compared with those of 25 controls. The aim of this study was to investigate if the two tests showed any direct correlation with the degree of spasticity and, furthermore, with other clinical measures that are present in patients with spasticity as part of an upper motoneuron syndrome (i.e., changes in muscle tone, reflexes, force, etc.). The results showed an abnormality of both tests in most patients (decrease of the three phases of inhibition in the reciprocal inhibition test and increase of the late facilitation part of the H-reflex recovery curve), and these abnormalities seem mostly to be related to muscle tone, most important being the degree of correlation between tone and changes in abnormality of the H-reflex recovery curve (P < 0.03).

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Clinical symptoms and/or signs of peripheral neuropathy were found in 17 of the 19 patients we studied with liver cirrhosis. In 16 of the 19 patients electrophysiological abnormalities were also observed. Mild-moderate alterations involved both motor and sensory fibres, with a higher incidence in the lower rather than upper limbs, and indicated a fibre loss rather than a fibre demyelination. These changes were observed in both alcoholic and non-alcoholic cirrhotics, suggesting a primary role of liver cirrhosis per se. In fact, both the clinical and electrophysiological abnormalities were related to the severity of the liver disease. A careful clinical examination could reveal the presence and extent of neuropathy in most cirrhotic patients.

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A patient with Gorlin-Goltz syndrome (nevoid basal cell carcinoma syndrome) is described. This disease has an autosomal dominant inheritance pattern with complete penetrance and extremely variable expressivity. The case report seems to represent a new mutation. Gorlin-Goltz syndrome is characterized by a lot of symptoms primarily involving the skin, central nervous system, and skeletal system. In 90% of the patients, nevoid basal cell carcinoma syndrome is associated with recurring odontogenic keratocysts. Also our patient showed recurrent jaw and maxillary cysts, for this reasons he has been followed for 10 years to the Oral Pathology Service of Galliera Hospital.

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We present a 2-year verbal and nonverbal follow-up of a crossed aphasic patient. The patient had suffered from widespread ischemic damage in the area of right middle cerebral artery, with a parieto-temporal lesion. Three months postonset he showed classical Wernicke's aphasia associated with oral, limb and constructional apraxia and left hemineglect. However, follow-up findings showed a complex, dynamic pattern entirely consistent with cognitive models of language and nonlanguage abilities. Current models of functional brain lateralizations could not satisfactorily account for such longitudinal, fine-grain observations.

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Body composition was measured in patients who underwent total laryngectomy for carcinoma and who were enterally fed throughout the postoperative period with full liquid artificial mixtures. The intestinal complications were very mild and required no changes in the nutritional program. Body sector sizes remained essentially unchanged until the end of the support, malnutrition did not occur and the postoperative local infection rate was very low. On the contrary, in patients fed with blenderized food, the amount of enteral infusion had to be reduced because of poor tolerance or abdominal discomfort; in this case caloric intake was largely inadequate. Fall in BW and BCM size and increase of TBNa/TBK ratio demonstrated a postoperative impairment of the nutritional status. Furthermore, the postoperative infection rate, the number of days with fever and the length of antibioticotherapy were higher than those observed in patients fed with full liquid mixtures.

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Two nonconsanguineous patients affected by I-cell disease (mucolipidosis II) are reported. I-cell disease, an oligosaccharidosis, is characterized by severe psychomotor retardation, marked shortness of stature, coarse facies, gingival enlargement, generalized bone demineralization, periosteal cloaking of long bones visible in early infancy, a rapid deteriorating course, and death from heart failure or bronchopneumonia, usually by the age of 5 years. This disorder is the result of a deficiency of glycoprotein N-acetylglucosaminylphosphotransferase activity, necessary for proper intracellular processing of lysosomal enzymes. Inheritance is autosomal recessive. It received the name I-cell disease because of several granular inclusions in the cytoplasm of cultured fibroblasts and amniotic fluid cells observed under phase contrast microscopy. These granules represent altered lysosomes. The two patients, reported here, had a very marked gingival hypertrophy and, for this reason, were referred to the Oral Pathology Service of Galliera Hospital. A gingivectomy was performed on patient 2 to improve the mastication, but few months later gingival hypertrophy reappeared.

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The etiology of generalized gingival enlargement is very heterogeneous. Pregnancy, drugs, systemic diseases, poor oral hygiene, and nutritional impairment can lead to gingival enlargement. This defect can also be presented in several malformation syndromes. Gingival fibromatosis, that may exist as an isolated abnormality or as part of a syndrome, is another condition with gingival enlargement. In this paper, the malformation syndromes with gingival hypertrophy and those with gingival fibromatosis are listed in tables.

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Somatosensory evoked potentials (SSEPs) to stimulation of the tibial nerve at the knee (TN-K) and ankle (TN-A), and the sural nerve at the ankle (SN-A), were recorded from 3 or 4 spinal levels during surgery for scoliosis in 11 neurologically normal subjects. With stimulation of all 3 nerves, the propagation velocity along the spine was nonlinear: it was faster over cauda equina and midthoracic cord than over caudal spinal cord. Over the mid-thoracic cord, TN-K SSEP propagation was faster than that of TN-A and SN-A SSEPs, whereas over the caudal spinal cord these values were similar on stimulation of all 3 nerves. These data suggest that fast conducting second order afferent fiber systems contribute to spinal cord SSEPs evoked by stimulating both mixed and cutaneous peripheral nerves.

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The aim of our research is to investigate the success of the vasoactive intracavernous therapy in subjects suffering impotence only on a neurological basis. We have submitted 50 subjects to a multisciplinary study including P.B.P.I., intracavernous minitest plus V.S.S., M.M.P.I., B.C.R. latency, duration, aspect and an hormonal screening (SH, LH, PRL, F. TEST, 17 BE2). The patients, or their partners, were instructed in the technique of self intracavernous injection (S.I.C.I.) of vasoactive drugs. Papaverine alone was given to 37 patients in a mean dose of 20.8 +/- 11.7 mg. Other 13 patients were treated with papaverine plus phentolamine in order to obtain a full erection. Comprehensive results of the treatment were judged at 80% effective: only 10 patients discontinued self injection treatment, unable to perform this technique properly.

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