Diagnostic and therapeutic pathway for pain in a Continuing Care setting: a survey at an Italian Continuing Care Service

Background

Law no. 38 of 15 March 2010 ensures and governs the access to the palliative care and pain management network for patients who require it. The professional roles involved in the project have been identified by the law, with the specific experience and expertise in the field of palliative care and pain management, by allocating a meaningful role to general practitioners (GPs). For this reason, an important direct training plan has been drawn up that GPs can count on for dedicated refresher courses to increase and deepen their knowledge in this specific clinical field. If the role of the GPs in the pain management and palliative care network was well-defined by the law, we cannot say the same for the Continuing Care Physician (CCP), a role that only partially overlaps that of the GP. The study observed the response of a Continuing Care Service (CCS) to the demand for services from patients with pain-related problems. The role of the CCP is, therefore, outlined in the pain therapy care network by observing the services provided to patients experiencing pain that is understood as being a non-deferrable problem.

Methods

A survey was conducted at the CCSs site in Aquila, AS-01 Abruzzo. For this reason, the attending physician records the data of patients who consult the CCSs for pain-related problems on an appropriate questionnaire. The survey period covered a total of 68 days (1 January - 8 March 2020). Results. One hundred sixty five sheets were completed; females were more represented than males (57.6% v 42.4%) and the 36-65 age group appears most greatly represented (47.9%). One of the most frequent reasons for consulting the service is "musculoskeletal pain" (58.2%), followed by abdominal pain (15.8%). In the majority of patients, pain lasted from days (53.9%), with an average of approximately 3 days (3.1± 2.9), or hours in 40% of cases, with an average of over 6 hours (6.54±3.1). 88.5% of patients defined the level of pain experienced as "severe" (NRS=7-10), and the intensity of the pain associated with its repetitiveness (80.3% vs 92.6%) as "severe", with a statistically significant difference in relation to nonrepetitiveness cases (p=0.02). 66.1% of patients said that they had taken analgesics independently, with nonsteroidal anti-inflammatory drugs (NSAIDs) the most frequently taken (53.5%). Patients who turned to the CCS received a pharmacological prescription in almost all cases. NSAIDs, specifically, were the most prescribed medicines (64.8%), followed by muscle relaxants (29.7%). Tramadol was the most represented among opioids, which was prescribed in 7.9% of cases. Just 6.1% of patients were entered into the regional pain management network.

Conclusions

The results of the survey show that a large number of patients turn to the CCS to resolve painful symptoms of various natures. The study offers some food for thought concerning the role of CCPs and the importance of providing for their inclusion in the pain therapy clinical and training pathways provided for by Law 38/2010. This would ensure its more effective implementation and, therefore, better care for patients experiencing painful pathologies.

Diagnosis of pediatric anti-NMDAR encephalitis at the onset: A clinical challenge

BACKGROUNDS

To investigate the clinical and instrumental features at the onset addressing to the diagnosis of anti-NMDAR encephalitis.

METHODS

Twenty children (age: 15 months-17 years; 7 males, 13 females) with initial suspected diagnosis of autoimmune encephalitis, observed between January 2008 and March 2018, were included. The final diagnosis was anti-NMDAR encephalitis in 7 children, other/probable autoimmune encephalitis in 7 children, and primary psychosis in the remaining 6 children.

RESULTS

At the clinical onset, anxiety disorder was the main symptom that helped in distinguishing the group of psychotic children from children with non-infectious encephalitis (P = 0.05 OR = 0.001), while epileptic seizures strongly predicted anti-NMDAR encephalitis (P = 0.04 OR = 28.6). At the onset, anti-NMDAR encephalitis could be distinguished from other/probable autoimmune encephalitis for the presence of sleep/wake rhythm alteration (P = 0.05 OR = 15). Among the symptoms occurring during the hospitalization, movement disorders (P = 0.031 OR = 12) were predictive of non-infectious encephalitis rather than primary psychosis. More specifically, the occurrence of language impairment (P = 0.03 OR = 33), epileptic seizures (P = 0.04 OR = 28.6) and catatonia (P = 0.03, OR = 33), were predictive of anti-NMDAR encephalitis. Also at this stage, anxiety disorder (P = 0.03 OR = 0.033) was predictive of primary psychosis.

CONCLUSION

Our findings suggest that at the clinical onset epileptic seizures and sleep/wake rhythm alteration represent the main features addressing to the diagnosis of anti-NMDAR encephalitis rather than primary psychosis and other/probable autoimmune encephalitis, while anxiety disorder could be a solid predictor of primary psychosis.

User interfaces for information systems

Se describen cuatro proyectos de interfaces de sistemas de información que se están desarrollando en ESRIN (establecimiento de la Agencia Espacial Europea, en Frascati). Cada uno de ellos muestra un enfoque diferente del diseño de interfaces, pero todos tienen en común el responder a los objetivos, tareas y características de los usuarios. Se sugiere que la próxima generación de sistemas de información científica se tendrá que diseñar para permitir el acceso directo de los usuarios finales a una gran variedad de fuentes de información a través de una interfaz común. El diseño de tales sistemas y de sus interfaces debería basarse en un análisis multinivel de objetivos, tareas y puntos de vista propios de la materia de trabajo de cada usuario.

Experimental Determination of Irreversible Entropy Production in out-of-Equilibrium Mesoscopic Quantum Systems

By making use of a recently proposed framework for the inference of thermodynamic irreversibility in bosonic quantum systems, we experimentally measure and characterize the entropy production rates in the nonequilibrium steady state of two different physical systems-a micromechanical resonator and a Bose-Einstein condensate-each coupled to a high finesse cavity and hence also subject to optical loss. Key features of our setups, such as the cooling of the mechanical resonator and signatures of a structural quantum phase transition in the condensate, are reflected in the entropy production rates. Our work demonstrates the possibility to explore irreversibility in driven mesoscopic quantum systems and paves the way to a systematic experimental assessment of entropy production beyond the microscopic limit.

From intravenous to enteral ketogenic diet in PICU: A potential treatment strategy for refractory status epilepticus

BACKGROUND

Ketogenic diet (KD) has been used to treat refractory status epilepticus (RSE). KD is a high-fat, restricted-carbohydrate regimen that may be administered with different fat to protein and carbohydrate ratios (3:1 and 4:1 fat to protein and carbohydrate ratios). Other ketogenic regimens have a lower fat and higher protein and carbohydrate ratio to improve taste and thus compliance to treatment. We describe a case of RSE treated with intravenous KD in the Pediatric Intensive Care Unit (PICU).

CASE REPORT

An 8-year-old boy was referred to the PICU because of continuous tonic-clonic and myoclonic generalized seizures despite several antiepileptic treatments. After admission he was intubated and treated with intravenous thiopental followed by ketamine. Seizures continued with frequent myoclonic jerks localized on the face and upper arms. EEG showed seizure activity with spikes on rhythmic continuous waves. Thus we decided to begin KD. The concomitant ileus contraindicated KD by the enteral route and we therefore began IV KD. The ketogenic regimen consisted of conventional intravenous fat emulsion, plus dextrose and amino-acid hyperalimentation in a 2:1 then 3:1 fat to protein and carbohydrate ratio. Exclusive IV ketogenic treatment, well tolerated, was maintained for 3 days; peristalsis then reappeared so KD was continued by the enteral route at 3:1 ratio. Finally, after 8 days and no seizure improvement, KD was deemed unsuccessful and was discontinued.

CONCLUSIONS

Our experience indicates that IV KD may be considered as a temporary "bridge" towards enteral KD in patients with partial or total intestinal failure who need to start KD. It allows a prompt initiation of KD, when indicated for the treatment of severe diseases such as RSE.

User interfaces for information systems

This paper presents descriptions of four informa tion/system interface projects in progress at ESRIN, the estab lishment of the European Space Agency (ESA) in Italy. Each project demonstrates a somewhat different approach to mter face design, but all share the commonality of responding to user goals, tasks and charactenstics. It is suggested that next generation scientific information systems will have to be designed for direct access by end users to a large vanety of information sources, through a common interface. Design of such systems, including their interfaces, should be based on a multi-level analysis of user goals, tasks and domain views.

Inter-laboratory evaluation of the EUROFORGEN Global ancestry-informative SNP panel by massively parallel sequencing using the Ion PGM™

The EUROFORGEN Global ancestry-informative SNP (AIM-SNPs) panel is a forensic multiplex of 128 markers designed to differentiate an individual's ancestry from amongst the five continental population groups of Africa, Europe, East Asia, Native America, and Oceania. A custom multiplex of AmpliSeq™ PCR primers was designed for the Global AIM-SNPs to perform massively parallel sequencing using the Ion PGM™ system. This study assessed individual SNP genotyping precision using the Ion PGM™, the forensic sensitivity of the multiplex using dilution series, degraded DNA plus simple mixtures, and the ancestry differentiation power of the final panel design, which required substitution of three original ancestry-informative SNPs with alternatives. Fourteen populations that had not been previously analyzed were genotyped using the custom multiplex and these studies allowed assessment of genotyping performance by comparison of data across five laboratories. Results indicate a low level of genotyping error can still occur from sequence misalignment caused by homopolymeric tracts close to the target SNP, despite careful scrutiny of candidate SNPs at the design stage. Such sequence misalignment required the exclusion of component SNP rs2080161 from the Global AIM-SNPs panel. However, the overall genotyping precision and sensitivity of this custom multiplex indicates the Ion PGM™ assay for the Global AIM-SNPs is highly suitable for forensic ancestry analysis with massively parallel sequencing.

The role of extracellular conditions during CaCo-2 cells growth: a preliminary study for numerical model validation

OBJECTIVES

One important limitation in cell therapy protocols, and regenerative medicine (an innovative and promising strategy for different pathologies treatment), is the lack of knowledge about cells engraftment, proliferation and differentiation. In order to allow an efficient and successful cell transplant, it is necessary to predict the logistics, economic and timing issues during cellular injection. It has been reported that several parameters, such as cells number, temperature and extracellular pH (pH0) value can influence metabolic pathways and cellular growth. Numerical analysis and model can help to reduce and understand the effects of the above environmental conditions on cell survival. The aim of this paper is to develop the first step of cells transplantation in order to identify "in vitro", which parameters can be useful to develop and validate a numerical model, able to evaluate "in vivo" cells engraftment and proliferation.

MATERIAL AND METHODS

We studied the variation of extracellular parameters--such as medium volume, buffer system, nutrient concentrations and temperature on human colon carcinoma cells (CaCo-2) "in vitro culture"--pursuing the goal of understanding in deeper details cellular processes such as growth, metabolic activity, survival and pH0.

RESULTS

Results showed that CaCo-2 cells growth and mortality increase after two days in culture when cells were suspended in 3.5 ml volume to respect of 10 ml volume. Different temperature values influenced CaCo-2 cells growth and metabolic activity showing a direct relationship with the volume of the medium.

CONCLUSIONS

Our results describe as CaCo-2 cell growth, metabolic activity, mortality and extracellular pH were influenced by extracellular parameters, enabling us to develop and validate a numerical model to be use to predict cells engraftment and proliferation.

Myocardial ischemia in cocaine-user with anomalous origin of the left circumflex coronary artery

The prevalence of anomalous coronary artery is approximately 0.6-1.7% in patients who undergo coronary angiography. These anomalies may cause angina, acute myocardial infarction, syncope and sudden death. Cocaine abuse is now a major health hazard: more than 5 million of Americans are current users. Cocaine abuse can result in coronary artery vasocostriction and the association between cocaine abuse, myocardial ischemia and infarction in the absence of coronary artery disease has been reported. We report the case of a patient with a story of nasally inhaled cocaine abuse presented with exertional chest pain and a perfusion defect of the anterior and inferior-lateral walls of the left ventricle during myocardial perfusion SPECT. The anomalous origin of the left circumflex coronary artery from the righ sinus of Valsalva was detected during coronary angiography and confirmed by the multislice computed tomography (MSCT). Although the coronary angiography is the gold standard of cardiac imaging technique for the diagnosis of coronary artery disease the identification of anomalous coronary arteries is frequently difficult with conventional coronary angiography because of the lack of 3-dimensional (3D) information related to the course of the coronary arteries to the great vessels. The MSCT provides a high spatial resolution, which allows a successful identification of the congenital coronary artery anomalies. This case report provides further a supportive evidence for the role of MSCT in the detection of the coronary artery anomalies.

Elasticity/distensibility of the ascending aorta: basal conditions and simulated conditions from space flights

INTRODUCTION

The hysto-morfological composition of the ascending aorta wall gives to the vessel its characteristic elasticity/distensibility, which is deteriorated due to both physiological (age) and pathological events (hypertension, diabetes, dyslipidemia). This contributes to reduce the wall elasticity and to occurrence of cardiovascular events.

MATERIALS AND METHODS

Thirty young healthy subjects (20 males, 10 females, age <30 yr), were subjected to different postural conditions with and without Lower Body Negative Pressure (LBNP) with conventional procedures, to simulate the microgravity conditions in space flight. During this procedure the cardiovascular parameters and the aorta elasticity were assessed with ecocardiography.

RESULTS

The observation of results and statistical comparison showed that despite different hemodynamic conditions and with significant variation of blood pressure related to posture, elasticity/distensibility did not change significantly.

DISCUSSION

The elasticity/distensibility of arterial vessels is the result of two interdependent variables such as blood pressure and systolic and diastolic diameters. While blood pressure and heart rate vary physiologically in relation to posture, the compensation of the vessel diameters modifications maintains the aortic compliance invariate. Therefore, in young healthy people, despite the significant postural and the sudden pressure changes (equivalent to parietal stress) aortic compliance does not alter. This behavior might be related to the low rate of cardiovascular events that are present in healthy people aged under 30 yrs.

Non-epileptic paroxysmal manifestations during sleep in infancy and childhood

Sleep-related paroxysmal disorders in infancy and childhood have recently been reviewed and classified by the American Sleep Disorders Association. Although in some patients diagnosis is easy to achieve, at times a video/EEG recording of the episodes is required because of the similarity to epileptic seizures. These disorders often represent a challenge for paediatricians as an accurate diagnosis is required. We report a review of the literature and a characterisation of our series of patients. Paroxysmal events during sleep are frequently misdiagnosed as psychogenic fits, epileptic seizures or physiologic events with evident disadvantages for children and families. The widespread use of neurophysiological techniques and better knowledge of the semeiology of epileptic seizures have led us to correctly define these events, which have sometimes been erroneously treated in the past.

Indications for surgical treatment of epilepsy in childhood: a clinical and neurophysiological approach

Resistant epilepsy is defined as the persistence of unacceptable seizures, despite correct drug treatment, or control of seizures at the cost of excessive side effects. About 30% of partial seizures are resistant to treatment; many of them is potentially a candidate for surgical treatment. Selection of patients is based fundamentally on precise identification of the epileptogenic area and on the evaluation that possible removal of that area will not be followed by serious neurological or neuropsychological deficits, or by onset of seizures in another part of the brain. To this end, careful clinical, neurophysiological and functional studies are conducted. Compared with adults, video-electroencephalographic (EEG) study of seizures in childhood is more difficult because of the lack of patient cooperation and, therefore, the lack of every subjective element in the seizures. Furthermore, the criteria for defining drug resistance in childhood are still under discussion, as many epilepsies are age dependent and seizures stop with growth. Despite this, the age at time of surgery has been steadily decreasing, in the conviction that the persistence of intractable partial epilepsy is detrimental to cognitive development and can damage brain areas that are apparently healthy. The clinical and EEG criteria for epilepsies that are secondary to some specific disorders have been defined, e.g. hemimegalencephalia and focal cortical dysplasias often produce epilepsy with onset in the first days of life characterized by partial seizures and subintrant spasms, EEG record of focal or hemispheric burst suppression and drug resistance that can be defined within the first months of life. Prolonged video-EEG monitoring is always necessary to establish congruence between the area in which the seizure originates and the brain lesion evidenced at neuroimaging. Correct monitoring of seizures means close cooperation between neurologist, neurophysiology technician and the patient, if the child is at least 5-6 y old. Absence of cooperation also limits the use of in-depth recording. Neuropsychological assessment of the child can be of great help in defining the area damaged by the epileptogenic site as well as the state of the other brain areas. Close cooperation between neurologist, radiologist, neuropsychologist and brain surgeon is necessary for a case-by-case assessment of indication for surgical treatment.

Experience with immunomodulatory treatments in Rasmussen's encephalitis

The authors investigated immunomodulatory treatments in 15 patients with Rasmussen encephalitis (RE) (14 with childhood and one with adolescent onset RE). Positive time-limited responses were obtained in 11 patients using variable combinations of corticosteroids, apheresis, and high-dose IV immunoglobulins. Although surgical exclusion of the affected hemisphere is the only treatment that halts disease progression, immunomodulation can be considered when early surgery is not feasible, in late-onset patients with slower disease progression, and in the few cases of bilateral disease.

Diagnostic imaging in 13 cases of Rasmussen's encephalitis: can early MRI suggest the diagnosis?

Rasmussen's encephalitis (RE) is a rare, progressive, chronic encephalitis characterised by drug-resistant epilepsy, progressive hemiparesis and mental impairment. It typically involves only one cerebral hemisphere, which becomes atrophic. We present neuroradiological findings in 13 children with RE. MRI was performed in all patients, fluorodeoxyglucose positron-emission tomography (PET) in three, Tc-99m hexamethylpropylenamine oxime single-photon emission computed tomography (SPECT) in two and proton MR spectroscopy ((1)HMRS) in two. MRI showed progression of the hemisphere atrophy, always prevalent in the region primarily involved (13 patients), spread of the abnormal signal in white matter (11) and cortex (10) and progression of atrophy of the head of the caudate nucleus (nine). Associated secondary changes were: atrophy of the contralateral cerebellar hemisphere (in four patients), the ipsilateral hippocampus (in five) and the brain stem (in five). The earliest CT and MRI abnormalities, seen between 1 day and 4 months after the first seizure (in 12 patients examined, nine of whom had MRI) in one cerebral hemisphere included: high signal on T2-weighted images in the cortex (seven patients) and white matter (nine), cortical atrophy usually involving the frontoinsular region, with mild or severe enlargement of the lateral ventricle (eight) and moderate atrophy of the head of the caudate nucleus (seven). Cortical swelling in the early stage of the disease was recognisable only in two patients. PET revealed hypometabolism, SPECT decreased perfusion, and (1)HMRS reduction of N-acetylaspartate in the affected hemisphere. PET and SPECT were usually performed in the late stages and did not provide specific findings. MRI thus demonstrates the progression of RE and may suggest the diagnosis in the early stages, often before the appearance of neurological deficits. Early diagnosis of RE may be crucial for selecting patients for aggressive medical therapy or major surgical interventions such as hemispherectomy.

Rasmussen's encephalitis: early characteristics allow diagnosis

OBJECTIVE

To identify early manifestations of Rasmussen encephalitis (RE) that can prompt early and reasonably secure diagnosis, allowing medical or surgical therapies at an early stage when they may be more effective in slowing the disease.

METHODS

The authors studied 12 patients with clinical and neuropathologic diagnosis of RE, followed from disease onset, assessing clinical history, imaging, and EEG and focusing on early characteristics. Anti-GluR3 antibody assays were also considered in 11 patients.

RESULTS

By 4 months from first symptoms, all cases had 1) refractory focal seizures with a predominant motor component, 2) slow focal activity on EEG contralateral to the motor manifestations, and 3) focal contralateral white matter hyperintensity with insular cortical atrophy on neuroimaging. Less constant or later findings were epilepsia partialis continua, oligoclonal bands, and serum anti-GluR3 antibodies.

CONCLUSIONS

The association of partial seizures with focal EEG and neuroimaging changes allows a tentative diagnosis of RE 4 to 6 months after first symptoms.

Neurophysiology of spasms

Spasms are a form of epileptic seizure typical of infancy. From a clinical point of view, the child presents a flexor-extensor movement involving the trunk and limbs and lasting about 1s. Although asymmetry can be present, the seizure involves both sides of the body. The ictal discharge most frequently associated with spasms in West syndrome (WS) is a diffuse triphasic slow high-amplitude wave and less frequently a low-amplitude brief rapid rhythm. The origin of the spasm in WS and classification as either partial or generalized seizure are the subject of much discussion. Factors supporting partial origin include: interictal electroencephalography (EEG) characterized by multifocal anomalies; high incidence of focal cortical lesions and remission of spasms following surgical removal of focal lesions. Factors supporting generalized origin are: clinical involvement of the entire body; mostly generalized ictal EEG pattern; existence of idiopathic cases and possibility of spasms immediately following a partial seizure like a particular form of secondary generalization. In our opinion, the categories of 'partial' and 'generalized' seizures are not applicable to spasms in WS. Sometimes the spasms in WS can be observed together with other types of partial or generalized seizures. Polygraphic recordings have demonstrated that despite being clinically similar, each spasm is different from the other because of a variable sequence in muscular contraction. These data support the peculiar nature of the spasm in WS that could be a subcortical phenomenon that requires a cortical trigger.

Video/EEG aspects of early-infantile epileptic encephalopathy with suppression-bursts (Ohtahara syndrome)

Early-infantile epileptic encephalopathy (EIEE) with suppression-bursts is a severe neonatal epileptic encephalopathy. The etiology is multiple, with cerebral malformations as the more frequent. We review the clinical and video/EEG aspects of eight infants with EIEE. These infants, aged between 4 and 70 days at the time of video/EEG recordings, were studied in relation to their clinical and video/EEG characteristics, evolution, persistence of suppression-burst pattern and etiology. Seven of the eight infants showed an ictal clinical sign correlated to the burst of the suppression-burst pattern, four of whom died within 11 months of age. The other three are alive. One, now aged 4 years, underwent surgery for hemimegalencephaly and is seizure-free, with good neurological outcome. One, now aged 9 months, was pyridoxine-dependent and she is seizure-free, and with normal neurological evolution under pyridoxine therapy. One, now aged 3 years and 9 months, is seizure-free, but with severe neurological and cognitive impairment. The only child who did not show a clinical ictal correlation of burst is also alive, now aged 3 years and 9 months, with drug-resistant epilepsy, and severe neurological and cognitive deficits. With regard to the etiology, three showed structural abnormalities, two more showed some signs of prenatal origin of neurological disease, and three had metabolic etiology. Our study confirms that EIEE is a severe age-dependent early epileptic encephalopathy. The etiology is mostly malformative. The prognosis is poor regarding motor and cognitive development, seizures, as well as life expectancies. The presence of an ictal burst of the suppression-burst pattern usually correlates with a negative outcome.

EEG discharges on awakening: a marker of idiopathic generalized epilepsy

In a series of 24-hour ambulatory EEG recordings from 1,000 consecutive adult outpatients (44.5% with generalized and 55.5% with partial epilepsy, one recording per patient), the authors found only 46 (4.6%) activations of epileptiform discharges on awakening. All recordings came from patients with idiopathic generalized epilepsy, predominantly with juvenile myoclonic epilepsy and generalized tonic-clonic seizures on awakening. Multiple spike discharges that develop with an unusually delayed onset after arousal (more than 10 minutes) might help to discriminate juvenile myoclonic epilepsy.

Benign myoclonus of early infancy

Benign myoclonus of early infancy, first described by Fejerman and Lombroso, is a paroxysmal phenomenon of the first 2 years of life which occurs in neurologically healthy infants during wakefulness, and is usually triggered by excitement or frustration. We studied the neurophysiological features of the phenomenon in five children, aged 7 to 11 months, who were monitored by video-EEG recording, and by polygraphic recording in 3 of the 5 cases. The phenomenon is characterized by a shudder-type, paroxysmal motor manifestation involving mainly the trunk and sometimes the head, associated with tonic limb contractions of variable intensity, from hardly noticeable to more sustained. The EEG counterpart never showed modifications, the polygraphic study demonstrated a brief tonic limb contraction. The clinical manifestation should not be confused with the spasms of epileptic infantile spasms syndrome, or with tonic reflex seizures of early infancy. Although the phenomenon is already widely known, its polygraphic recording is rarely reported in literature. The polygraphic data of our patients contributes to the diagnosis and understanding of the pathophysiology of this paroxysmal manifestation.

Repetitive sleep starts in neurologically impaired children: an unusual non-epileptic manifestation in otherwise epileptic subjects

Sleep starts, also called hypnagogic or hypnic jerks, are bilateral, sometimes asymmetric, usually single, brief body jerks that coincide with sleep onset. We describe sleep starts occurring repetitively in three epileptic children with spastic-dystonic diplegia and mental retardation. Repetitive sleep starts began at age 18 months in two children and at 9 months in the third. All three children had had feto-neonatal asphyxia; two presented with spastic and one with dystonic tetraparesis. One had West syndrome and two had partial motor seizures in the first year of life. Seizures were controlled in all three patients by antiepileptic drug therapy. Video/EEG recordings of all the children during the afternoon nap revealed clusters of sleep starts during the transition between wakefulness and sleep. Cluster lasted 4-15 min and comprised from twenty to twenty-nine contractions. The EEG counterpart of the event sometimes showed an arousal response, at times inducing complete awakening. Repetitive sleep starts should be recognized and clearly differentiated from epileptic seizures, especially if they appear in epileptic subjects. In neurologically compromised patients, they could represent an intensification of an otherwise normal event, due to the lack of strong inhibitory influence of the pyramidal tract resulting from the pyramidal lesion.

Efficacy and tolerability of vigabatrin in children with refractory partial seizures: a single-blind dose-increasing study

The efficacy and tolerability of vigabatrin (VGB) in children with refractory partial epilepsy were assessed in a single-blind, add-on, fixed-sequence, placebo-controlled trial. After 1-month observation, the patients entered a 7-month treatment period that involved administration of placebo for 1 month followed by VGB at the initial dosage of 40 mg/kg/day, to be increased to 60 and 80 mg/kg/day at 2-month intervals if seizures persisted. Of the 46 children enrolled in the study, 7 dropped out prematurely due to lack of efficacy of the drug (n = 6) or increased seizure frequency (n = 1). In 11 patients who either became seizure-free (n = 3) or improved markedly (n = 8), treatment was completed at a dose < 80 mg/kg/day. The average number of seizures per month in the 39 patients who completed the study decreased from 97 during placebo to 21, 12, and 9 after 2, 4, and 6 months of VGB treatments respectively (p < 0.0001 at each time). Response to VGB remained statistically significant when dropouts were included in the evaluation. The number of patients who had > 50% reduction in seizure frequency after 2, 4, and 6 months was 28, 33, and 35, respectively. Eight patients became seizure-free during the last 2 months of VGB treatment (3 at 40, 3 at 60, and 2 at 80 mg/kg/day, as compared with none during placebo treatment). Serum levels of associated antiepileptic drugs (AEDs) showed no significant changes, except for serum phenytoin (PHT) concentration, which significantly (p < 0.01) decreased after VGB treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Reflex myoclonic epilepsy in infancy: a new age-dependent idiopathic epileptic syndrome related to startle reaction

Benign myoclonic epilepsy of infancy (BMEI) is an idiopathic disorder characterized by spontaneous myoclonic attacks with onset in the first 2 years of life. We observed 6 neurologically normal infants (aged 6-21 months) with attacks that resembled those of BMEI but that occurred as reflex responses to unexpected auditory and tactile stimuli. four infants also had rare spontaneous attacks. These reflex attacks consisted of isolated muscle jerks or clusters of up to eight symmetric limb jerks affecting mainly the arms. Five of the children had a family history of epilepsy or febrile convulsions. Myoclonic attacks disappeared in 4-14 months. In 3 patients, the jerks stopped spontaneously; the others responded to valproate (VPA). Myoclonus could be elicited in wakefulness and in sleep. Ictal EEGs showed brief generalized spike- or polyspike-and-wave discharges. Interictal EEGs were normal during wakefulness; during sleep, brief generalized discharges were evident. We propose that reflex myoclonic epilepsy of infancy (RMEI) is a new age-dependent idiopathic generalized epileptic (IGE) syndrome, with an apparently good prognosis.

Benign infantile familial convulsions are not an allelic form of the benign familial neonatal convulsions gene

Benign infantile familial convulsions (BIFC) and benign familial neonatal convulsions (BFNC) are two forms of familial convulsions having an age of onset within the first year of life. The gene responsible for BFNC has been mapped to chromosome 20q in the close vicinity of D20S19 and D20S20 markers. We performed linkage analysis between BIFC and D20S19-D20S20 in eight families in order to know whether the BFNC gene is also implicated in BIFC. Several apparent obligate crossovers between affected members were detected. The data here presented demonstrate that the BFNC gene is not responsible for BIFC.

The idiopathic form of West syndrome

The clinical and electroencephalographic data of 31 children with cryptogenic West syndrome (WS), selected from a series of 103 WS patients, with a follow-up between 4 and 12 years, were studied retrospectively to verify whether this group included patients who fulfilled the criteria for an idiopathic etiology. The results identified a possible idiopathic etiology in 17 patients (55%), who had a family history of other forms of idiopathic epilepsy or febrile convulsions, or who developed, during the follow-up, an EEG genetic trait such as a photoconvulsive response or spike-and-wave discharges, or rolandic spikes. All 17 children had a favorable outcome and all had normal neuropsychological development. Four children (13%) fulfilled the criteria for a true cryptogenic etiology, a causative lesion being suspected, but never proved. At the end of the follow-up all four had seizures, or developmental delay or both, all signs that suggest an underlying cerebral lesion. The other 10 children, representing 32% of the cryptogenic cases, had a good prognosis, with early disappearance of spasms and hypsarrhythmia, and normal neurological development, but none had an EEG epileptic trait or family history of epilepsy or febrile convulsions; although they could have had an idiopathic WS, this was not proved. We conclude that among the children classified as having a cryptogenic WS, many--in our series at least 55%--fulfill the criteria for an idiopathic etiology.

Ictal clinical electroencephalographic findings of spasms in West syndrome

The electroencephalographic/video recordings of 955 spasms in children with cryptogenic and symptomatic West syndrome (WS) were reviewed to define the relation between a clinical manifestation of a spasm and its EEG pattern, and to examine whether these features reflect the etiology and prognosis of WS. The review confirmed the spasm to be a distinct type of seizure, with a unique clinical and EEG pattern unlike that of all other recognized seizures. Symmetric spasms were present in cryptogenic and symptomatic patients. In contrast, asymmetric spasms, or focal signs recognizable during a spasm, strongly indicated the existence of a cerebral lesion. In both etiological groups, the characteristic ictal EEG pattern of the spasms consisted of a positive-vertex slow wave. The other two patterns apparently correlated to a spasm, were fast activity, here called spindle-like, and decremental activity. The fast activity corresponded to a clinical stare, and the decremental activity, when present, represented a postictal event. Although it was independent from the etiology of the spasms, persisting hypsarrhythmia during a cluster of spasms appeared to be an EEG pattern that correlated with a favorable outcome.

Benign neonatal sleep myoclonus: clinical features and video-polygraphic recordings

Benign neonatal sleep myoclonus is a syndrome characterized by the occurrence of repetitive myoclonic jerks of the extremities exclusively during non-rapid eye movement sleep in the early life of healthy newborns. No etiological factors are present. The onset is within the first 15 days of life with spontaneous disappearance within 3-4 months. These myoclonic events are commonly diagnosed as epileptic seizures. We observed 12 newborns with this clinical pattern; the follow-up ranges from 12 to 60 months. Long-term videopolygraphic electroencephalographic (EEG) monitoring demonstrated normal EEG activity, thus confirming that these unusual events were nonepileptic.

Hypnic tonic postural seizures in healthy children provide evidence for a partial epileptic syndrome of frontal lobe origin

In the pediatric age period, three idiopathic partial epileptic syndromes are recognized: benign childhood epilepsy with centrotemporal spikes, childhood epilepsy with occipital paroxysms, and primary reading epilepsy. All other partial epilepsies are considered cryptogenic, and no other idiopathic partial epilepsies have been recognized. We observed 10 children with tonic partial postural seizures, mainly hypnic, coinciding with a recognizable ictal epileptiform EEG pattern. The children all had normal neuropsychological development before and after seizure onset. The seizures were tractable in all. Onset was in the early pediatric age period; no other type of seizure was recognized. The occurrence of a family history of epilepsy was high. The seizure pattern was typical of supplementary motor area origin. Because of the normal neuropsychological status, high familial incidence of epilepsy, and benign course of this partial epilepsy, we believe it should be considered idiopathic, using the criteria of the International Classification of Epilepsies and Epileptic Syndromes. We therefore suggest the existence of a partial idiopathic epileptic syndrome having onset with seizures of frontal lobe origin.

Epilepsia partialis continua and neuronal migration anomalies

Neuronal migration anomalies commonly cause seizures that are partial in type and generally refractory to medical treatment. Epilepsia partialis continua (EPC), an unusual form of epilepsy commonly related to acute damage of the cerebral cortex or to a chronic lesion, has never been described in a patient with neuronal migration anomalies. In 50 children with epilepsy due to neuronal migration anomalies, we observed two cases of EPC. These two children had unilateral neuronal migration abnormalities with partial seizures other than EPC and contralateral hemiparesis. Epilepsia partialis continua appeared two to three years after the onset of partial attacks and was accompanied by a worsening of the children's previous hemiparesis. Although a rare seizure manifestation in children with neuronal migration anomalies, when it does appear, EPC can aggravate the clinical neurological condition and should always be investigated for in these cases. Because its clinical appearance is often subtle, as in these two children, EPC may easily remain undiagnosed.

Benign infantile familial convulsions

Five infants, three girls and two boys, first had convulsions between the ages of 4 and 6 months. Although the aetiology of the attacks was unknown, all the infants had a family history of similar convulsions occurring at the same age and having a benign outcome. The attacks, which always occurred in a cluster, were promptly controlled, in four cases with phenobarbital and in one case with valproate. Seizures were partial with secondary generalization and were characterized by head and eye deviation (not always the same side in each attack) diffuse hypertonia and then bilateral limb jerks. The interictal EEG was normal. The ictal EEG showed diffuse discharge with onset in the central-occipital region. Laboratory, radiological and neurological findings were normal. A history in at least one paternal relative (the father in four cases) of similar seizures, occurring at the same age suggested a genetic predisposition. No seizures or EEG anomalies were observed during the follow up.

Hemimegalencephaly and normal intellectual development

Hemimegalencephaly is a rare congenital malformation characterised by overgrowth of one hemisphere. Although it is commonly thought to be associated with neurological deficits, developmental delay, and intractable epilepsy, the clinical expression of hemimegalencephaly, can vary widely. This patient was neurologically and neuropsychologically normal apart from rare partial seizures.

Double cortex. A neuronal migration anomaly as a possible cause of Lennox-Gastaut syndrome

Band heterotopia, or "double cortex," is a neuronal migration disorder that consists of a symmetrical subcortical neuronal band. The overlying cortex may be normal or macrogyric. We describe two severely mentally retarded girls, aged 14 and 18 years, who had band heterotopia and Lennox-Gastaut syndrome. Band heterotopia was evident in both hemispheres as a subcortical symmetrical layer isointense with gray matter on magnetic resonance T1- and T2-weighted images. Both patients had atonic seizures, atypical absences, and tonic seizures. The electroencephalograms in both cases showed frequent generalized paroxysms and slow background activity. The association of a Lennox-Gastaut syndrome with double cortex in these two patients and in a previously reported autopsy-confirmed case suggests that this malformation may be responsible for other similar cases.

Reversible operculum syndrome caused by progressive epilepsia partialis continua in a child with left hemimegalencephaly

In a child with left hemimegalencephaly and seizures, a reversible operculum syndrome developed when continuous epileptic discharges spread from the left hemisphere to the contralateral central regions. The operculum syndrome lasted for three months until left hemispherectomy was performed. Soon after surgery the seizures and the operculum syndrome resolved. The operculum syndrome is a facio-pharyngo-glosso-masticatory diplegia usually due to structural lesions in both opercular regions. The reversibility of the syndrome in the reported case demonstrates that the operculum syndrome is sometimes functional rather than lesional.

Long-term EEG monitoring in uremic children on chronic dialysis treatment

Even in the absence of clinically apparent seizures, patients undergoing chronic dialysis often exhibit abnormal EEG activity, which is usually attributed to the type of dialysis or to the dysequilibrium syndrome. To find out whether these abnormalities occurred only during dialysis sessions, 10 children with end-stage renal failure undergoing chronic dialysis were continuously monitored for 52 h during dialysis and between two sessions. The EEG tracing was abnormal in 5 children. Two had paroxysmal aspecific slow waves towards the end of the sessions, with a fall in blood pressure, malaise and fainting. In 3 children EEG abnormalities - also present in the interdialytic period - were not clinically apparent. Long-term EEG monitoring in these cases distinguished between the electrical events that were related to dialysis and those that were not. It also suggested that, rather than being dialysis-dependent, these events frequently reflect a basic neurological disorder.