Early onset absence epilepsy of childhood: Epidemiologic data, treatment and outcome in a sample of 56 patients born between 2000 and 2018

PURPOSE

The aim of our work is to describe the characteristics of Early Onset Absence Epilepsy (EOAE) and to observe whether specific anamnestic, clinical or electroencephalographic characteristics can influence the drug sensitivity of this pathology.

METHODS

We carried out a retrospective study of patients affected by absence epilepsy with onset under four years of age, born between January 1st 2000 and December 31st 2018, who were reffered to the Regional Epilepsy Center of Spedali Civili of Brescia. We then divided the sample into three groups based on the age of onset.

RESULTS

Our sample is composed of 56 patients. Among the children with epilepsy onset under two years of age (11), all were still on therapy after three and six years of follow-up, and 64 % of them required polytherapy. Among patients with epilepsy onset between two and three years of age (24), 87 % were still on therapy after three years of follow-up and 68 % after six years of follow-up; 46 % of these subjects required polytherapy. Among patients with epilepsy onset between three and four years of age (21), 89 % were still on therapy after three years of follow-up and 38 % after six years of follow-up; 38 % of them required polytherapy.

CONCLUSIONS

We observe that patients with an earlier epilepsy onset have a worse outcome and a lower drug sensitivity. This may allow to predict in which cases it would be appropriate to maintain antiseizure therapy for a prolonged period.

A method for bivalve shells characterization by FT-IR Photoacoustic Spectroscopy as a tool for environmental studies

Fourier Transform Infrared Spectroscopy has been employed to investigate the composition of the shells of two marine bivalves Mytilus galloprovincialis and Corbula gibba from four samples collected from the Mar Piccolo of Taranto (Ionian Sea, Southern Italy). Bivalve shells are composed of 95–99.9% calcium carbonate (CaCO₃), while the remaining portion is constituted by organic matrix, which in some cases may incorporate pollutants from the surrounding environment. Recognizing the role of bivalves in the carbon biogeochemical cycle and their economic importance for aquaculture, we aimed to develop a methodology for shells powder samples preparation and analysis. The main objective of the study was to demonstrate the feasibility of Fourier Transform Infrared photoacoustic spectroscopy to perform a fast sample analysis in order to detect the possible presence of pollutants in the shells.

The results revealed an unbiased differentiation between the shell compositions of the two bivalve selected species. Moreover, the spectra interpretation indicated that C. gibba specimens recorded a shell matrix contaminated by organic pollutants present in the surrounding environment. In conclusion, the described methodology including sample preparation tailored for photoacoustical investigations demonstrated to be a tool for the characterization of bivalve shells contamination enhancing environmental studies of polluted marine areas.•

Bivalve species were collected from sampling stations located in the Mar Piccolo of Taranto (Ionian Sea, Southern Italy).

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Samples preparation stages include: sonication, grinding and fractioning by sieving.

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FT-IR PAS spectral region of interest is in the mid-infrared between 4000 and 400 cm⁻¹.

Depression and post-traumatic stress disorder symptoms during the COVID-19 pandemic in Italy

Introduction

Social restrictions imposed by the Italian Government during the COVID-19 emergency might have had a significant impact on mental health. The purpose of this study was to estimate the prevalence of depressive and post-traumatic stress disorder (PTDS) symptoms in a sample of Italian citizens during the first COVID-19 pandemic wave.

Materials and methods

A cross-sectional survey was carried out between April and June 2020 using a snowball sampling. Depressive symptoms were explored through the Patient Heath Questionnaire-2 (PHQ-2), while the post-traumatic stress disorder (PTDS) was investigated through the SPAN (Startle, Physical arousal, Anger, Numbness) questionnaire. Poisson regression models were used to explore the association between the outcomes under study and sociodemographic/housing characteristics.

Results

A total of 10.758 interviews were collected and 7.847 (73%), complete for a minimum set of indicators (age, sex, area of residence), were included in the final analysis. The majority of the respondents were females (71%). Sample mean age was 48.6 years. The prevalence of depressive symptoms was 21.2% and that of PTDS was 43.8%. Symptoms of depression and PTDS significantly diminished across age groups, in particular in people over 70 years compared with people aged 14-29 years (PR 0.65, 95% CI 0.49-0.86). A higher prevalence was found in students compared with retired people, both for depressive symptoms (PR 1.49, 95% CI: 1.05-2.10) and PTDS (PR 1.31, 95% CI: 1.02-1.69).

Conclusions

Prevalence of depressive and PTDS symptoms was high, in particular among younger people and students. That could potentially lead to adverse mental health outcomes in the future, with serious public health consequences. As the pandemic emergency is not solved yet, it is necessary to implement preventive strategies in order to protect the mental well-being of particularly vulnerable subgroups in the population.

Key messages

The prevalence of psychological symptoms was high in this sample during the first wave of COVID-19 pandemic.

The subgroups of the population at higher risk for adverse psychological outcomes were younger people and students.

Quelles sont les conséquences de l’épidémie COVID-19 sur l’organisation des soins ?

Introduction

Le 30/01/2020, l’OMS déclare une urgence de Santé Publique de portée internationale suite à l’épidémie de COVID-19. Les conséquences des épidémies sont nombreuses, aussi bien pour les patients que pour l’ensemble du système de santé. Cette étude a pour but d’évaluer les conséquences de l’épidémie COVID-19 sur l’organisation des soins à l’échelle hospitalière.

Matériels et méthodes

Nous avons récolté des données sur la réponse épidémique dans un hôpital prenant en charge des patients infectés par le SARS-CoV-2 à l’aide de plusieurs sources : entretiens individuels semi-structurés, périodes d’observation ethnographique in situ et analyse documentaire. Les entretiens ont été réalisés auprès des différents professionnels de l’hôpital. Les différents points de vue et niveaux organisationnels ont été envisagés lors des entretiens à l’aide d’une approche adaptative et itérative. Les entretiens étaient enregistrés, transcrits et codés à l’aide du logiciel NVivo 12. Les données qualitatives ont été analysées par une analyse thématique inductive.

Résultats

Nous avons réalisé 37 entretiens avec des personnels de santé (infirmier/e/s, médecins, aides-soignant/e/s, manipulateurs radiologiques, cadres de santé) dans plusieurs services (urgences, maladies infectieuses, réanimation, chirurgie cardiaque, équipe d’hygiène) et avec des personnels administratifs (personnel de sécurité, de logistique, de communication et de direction). Nous avons également collecté plus de 100 heures d’observation ethnographique. Concernant la réponse à l’épidémie, nous avons identifié des éléments facilitateurs comme la gestion de cas suspects pour les épidémies antérieures (MERS-CoV et Ebola), la réalisation d’exercices réguliers par l’équipe d’hygiène, et l’existence préalable de protocoles mais aussi des problèmes non anticipés comme la gestion des déchets à risques biologiques, des difficultés à recruter des infirmiers intérimaires ou la pression médiatique et les rumeurs. Les conséquences de l’épidémie ont été directes ; réorganisation du service de maladies infectieuses, de réanimation médicale et de virologie mais également indirectes ; diminution de l’activité de l’équipe mobile d’infectiologie et des activités d’enseignement, inquiétude des patients non concernés et annulation de rendez-vous. Ont été soulignés par les participants l’importance de maintenir la cohésion des équipes entre personnels travaillant auprès de patients infectés par le SARS-CoV-2 et personnels non impliqués, d’intégrer de façon harmonieuse la recherche clinique dans la prise en charge médicale et de réaliser un travail de veille bibliographique en temps réel afin d’actualiser la prise en charge des cas possibles et confirmés.

Conclusion

L’épidémie COVID-19 a eu de nombreuses conséquences sur l’organisation aussi bien des services médicaux concernés que des services non directement impliqués et des services administratifs. Cette étude permet d’identifier des pistes d’amélioration pour la réponse épidémique.

The role of laparoscopic surgery in isolated adrenal metastasis: our personal experience

BACKGROUND

Over the past 25 years, mini-invasive adrenalectomy has become the treatment of choice for most adrenal diseases, and even adrenal malignancies in selected cases. The aim of this retrospective evaluation is to assess the effectiveness of laparoscopic adrenalectomy as a treatment of choice for adrenal metastases.

METHODS

From 2008 to 2018, 207 laparoscopic adrenalectomies have been performed in our Department of Surgery. Among these, in 12 cases the indication to adrenalectomy was metastatic adrenal lesion.

RESULTS

The right adrenal gland was removed in 8 cases and the left adrenal gland in 4 cases. A complete resection (R0) was achieved in all patients. The median operative time was 130.6 ± 23.3 min. The median postoperative hospitalization was 3.5±2.0 days. Only one patient showed postoperative grade II complications, according to Clavien-Dindo classification. All patients underwent follow-up at 6-12-18 months without showing disease recurrence. There was no intra and perioperative mortality. Conversion to laparotomic surgery has never been performed. Mean tumor size was 2.4 cm ±1.6 cm.

CONCLUSIONS

Laparoscopic adrenalectomy for metastasis permits to achieve similar results to the open approach in term of oncological outcomes, but gaining in terms of postoperative hospitalization, intra and post-operative complications as well a greater patient compliance.

Voice prosthesis rehabilitation after total laryngectomy: are satisfaction and quality of life maintained over time?

Total laryngectomy is the standard of care for advanced laryngeal/hypopharyngeal cancer. Effective voice rehabilitation is mandatory and tracheo-oesophageal speech (TES) has progressively gained approval. In 2011, we evaluated quality of life (QoL) and satisfaction after TES rehabilitation, demonstrating its efficacy in highly motivated subjects. The aim of the present study was to investigate whether those results are maintained over time within the same selected cohort. 15 of 24 patients were left with a minimum 12 year-follow up after voice prosthesis (VP) implantation. Short Form 36-Item Health Survey (SF-36) for QoL assessment and a study-specific structured questionnaire for evaluation of TES-related satisfaction were employed. The 9/24 patients who dropped out from the follow-up were excluded from the original count and the former results were recalculated. A control group of subjects with minor ENT diseases was used for SF-36 analysis. Many SF-36 items (RP, BP, SF, RE) significantly improved over time, approaching the results of the control group. VP duration also increased (6.3 ± 3.1 against 3.0 ± 1.8 months). TES-related satisfaction items did not change in a statistically significant way. Three patients (20.0%) would not have chosen the same kind of voice restoration: these subjects are those more distant from our institution (230 km and 462 km, respectively, against a mean distance of 15.4 ± 13.8 km for other patients). With the present work, we highlight how the striking results of TES can not only be maintained over time (i.e. TES-related satisfaction), but also substantially improve (i.e. QoL). An integrated, widespread network of centres for VP management is needed to optimise patient follow-up and allow studies on larger series.

P05.08 High-grade gliomas and immunotherapeutic early phase clinical trials: a single-center experience

BACKGROUND

Patients with high-grade gliomas (HGGs) have historically been excluded from immunotherapeutic early-phase clinical trials (ieCTs) due to unavailability of serial bioptic sampling, the frequent need of corticosteroids, concerns regarding activity of immunotherapy in central nervous system, and rapid clinical deterioration.

MATERIAL AND METHODS

We retrospectively reviewed data of all recurrent HGG patients enrolled in ieCTs at Humanitas Cancer Center Phase I Unit between 2014 and 2019. Disease control rate (DCR) according to RANO criteria, six-months progression-free and overall survival (PFS-6; OS-6), and treatment-related adverse events (TRAEs), were evaluated. A control-cohort (CC) of patients treated with standard treatments (temozolomide, fotemustine, lomustine and procarbazine, bevacizumab) matched (1:1) for sex, age, line of treatment, MGMT methylation status, and IDH mutational status, was selected for comparison. A series of clinical parameters with an established prognostic value for patients with solid tumors treated into ieCTs were correlated with survivals through an univariate analysis. These include: use of steroids, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, lactate dehydrogenase, albumin, total protein.

RESULTS

Five among the 23 ieCTs conducted at our Phase I Unit allowed inclusion of HGG patients. 25 patients were enrolled in the experimental cohort (EC): 22 (88%) glioblastoma, 3 (12%) anaplastic astrocytoma. Median age was 50 years (range 25–71); 16 patients (64%) were men, 9 (36%) women; 17 pts (68%) required steroid therapy, with a median baseline dexamethasone dose of 2 mg (range 1–6). The median number of prior systemic therapies was 1 (range 1–2). Twelve patients (48%) received monotherapies (anti PD-1, anti CSFR-1, anti TGF-ß, anti cereblon), 13 (52%) combination regimens (anti PD-L1 + anti CD38, anti PD-1 + anti CSFR-1). DCR was 40% (1 CR + 2 PR + 7 SD) and 37% (9 SD), in EC and CC, respectively. Four patients (16%) in EC had grade ≥3 TRAEs (1 neutropenia, 1 pneumonia, 2 hepatitis). With a median follow-up of 14 months PFS-6 were 35% and 16% (p=0.075), in EC and CC respectively, while OS-6 was significantly improved in the EC (82% vs 44%, p=0.004). In our small series, none of clinical factors resulted prognostic.

CONCLUSION

Survival outcomes of ourHGG patients treated into ieCTs compared very favorably with a matched CC. Inclusion of HGGs patients into ieCTs should be strongly encouraged. Identification of clinical factors to select who may benefit from ieCTs still remains crucial.

The supraclavicular artery island flap (SCAIF) in head and neck reconstruction: an Italian multi-institutional experience

The supraclavicular artery island flap (SCAIF) is a thin and pliable pedicled flap that is easy and quick to harvest. Thanks to its particular features and high reliability, it is best indicated for the elderly or most fragile patients. SCAIF is very versatile, as it can be used for reconstruction of oral cavity, oropharynx, hypopharynx, facial and cervical skin and tracheostomal defects. We began using this flap in four Italian tertiary referral centres, with several indications, both as first treatment and as salvage surgery. The aim of the study was to demonstrate the easy reproducibility of the flap among four different centres. A series of 28 patients underwent head and neck reconstructions with SCAIF with no recorded complications during flap harvesting. After the very first cases, harvesting time was approximately 45 minutes; 24 patients had successful flap integration at the recipient site, while the remaining 4 suffered from partial flap necrosis, two of whom needed revision surgery. Other minor complications were reported at the recipient site, always at the most distal and most delicate portion of the flap. Donor site was always closed primarily, with only three cases of partial suture dehiscence. We only selected the most fragile patients for SCAIF reconstruction, such as the elderly or those with one or more comorbidities; for this reason, we reported some serious systemic complications and one intraoperative death. SCAIF is an easy reproducible flap, with multiple possible indications. Its use as an alternative to free flaps in the head and neck region is nowadays under discussion. Its use should be encouraged among head and neck surgeons thanks to its various advantages.

Radial vs ulnar forearm flap: a preliminary study of donor site morbidity

The objective of this study was to compare donor site morbidity after reconstructive surgery with Ulnar Forearm Free Flap (UFFF) and Radial Forearm Free Flap (RFFF) with subjective methods. The UFFF and the RFFF were applied for reconstruction of soft tissue defects of the head and neck region in 30 patients (20 M and 10 F; age range 28-75 years) affected by head and neck squamous cell carcinoma. The Disability of Arm, Shoulder and Hand (DASH) questionnaire was used to assess morbidity of the donor site. Analysis of the patients’ DASH scores showed an overall median DASH total score of 9.17. No significant differences were observed for median values of the RFFF and UFFF groups (7.14 vs 10 respectively) or for the values in males and females (5 vs 13.3 respectively). The UFFF can be considered a valid alternative to the RFFF for reconstruction of soft tissue defects of the head and neck area; it is safe, easy to harvest and is not associated with major morbidities of the donor site as demonstrated by the DASH questionnaire.

Electroclinical findings and long-term outcomes in epileptic patients with inv dup (15)

OBJECTIVE

To define the electroclinical phenotype and long-term outcomes in a cohort of patients with inv dup (15) syndrome.

MATERIAL AND METHODS

The electroclinical data of 45 patients (25 males) affected by inv dup (15) and seizures were retrospectively analysed, and long-term follow-up of epilepsy was evaluated.

RESULTS

Epilepsy onset was marked by generalized seizures in 53% of patients, epileptic spasms in 51%, focal seizures in 26%, atypical absences in 11% and epileptic falls in 9%. The epileptic syndromes defined were: generalized epilepsy (26.7%), focal epilepsy (22.3%), epileptic encephalopathy with epileptic spasms as the only seizure type (17.7%) and Lennox-Gastaut syndrome (33.3%). Drug-resistant epilepsy was detected in 55.5% of patients. There was a significant higher prevalence of seizure-free patients in those with seizure onset after the age of 5 years and with focal epilepsy, with respect to those with earlier epilepsy onset because most of these later developed an epileptic encephalopathy (69.2% vs 34.4%; P = .03), usually Lennox-Gastaut Syndrome in type. In fact, among patients with early-onset epilepsy, those presenting with epileptic spasms as the only seizure type associated with classical hypsarrhythmia achieved seizure freedom (P < .001) compared to patients with spasms and other seizure types associated with modified hypsarrhythmia.

CONCLUSIONS

Epilepsy in inv dup (15) leads to a more severe burden of disease. Frequently, these patients show drug resistance, in particular when epilepsy onset is before the age of five and features epileptic encephalopathy.

Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

Aims and background

Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.

Methods

Women eligible for invitation - 8385 for cervical and 8069 for breast cancer screening - listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A - letter signed by the GP, with a prefixed appointment; Group B - open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C - letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D - extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).

Results

Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).

Conclusions

Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored.

Breast Cancer Screening: Characteristics and Results of the Italian Programmes in the Italian Group for Planning and Evaluating Breast Cancer Screening Programmes (GISMa)

In 1990, GISMa (Italian Group for planning and evaluating Mammographic Screening - Gruppo Italiano per la pianificazione e la valutazione dei programmi di Screening Mammografico), a working group of operators (radiographers, radiologists, epidemiologists, clinicians, surgeons) involved in screening programmes ongoing in Italy, was created within the Italian School of Senology. The aim of this study is to illustrate data, presented at the GISMa meeting held in April 1994, concerning the characteristics of each programme and some early indicators of effectiveness. To assess these parameters (concerning compliance level, recall rate, benign/malignant biopsy ratio, detection rate, stage distribution, nodal involvement and number of cancers with a diameter under 1 cm, rate of cancer, etc.), ‘acceptable’ and ‘desirable’ standards obtained from Italian and North-European cancer screening experiences have been adopted. Most programmes have shown an acceptable standard for most of the indicators, and many of them have attained desirable levels. In most screening programmes the occurrence of interval cancers has not yet been measured, but all centres have (or are working to set up) a systematic active procedure to collect the data. The results indicate that common guidelines can be adopted, even when working in very heterogeneous contexts, and that it is possible to achieve a very high effectiveness and efficacy level. As regards quality control and cost/benefit issues, the goal of extending centralised, population-based screening programmes to other Italian regions becomes a priority.

General Practitioners and Mammographic Screening Uptake: Influence of Different Modalities of General Practitioner Participation

Aims and background

To compare the impact of different modalities of general practitioner (GP) involvement, including the introduction of target payments, on the attendance rate of organized population-based screening programs for breast cancer in Italy.

Study design

The study was conducted between 1994 and 1996 in four Italian cities where mammographic screening programs are active: Caltanissetta (CL), Firenze (Fl), Modena (MO) and Torino (TO). The impact on attendance rate of different invitation strategies based on active GP involvement was tested in each center. The additional effect of economic incentives was also assessed. The incentives were proportional to the level of compliance attained by each GP and weighted by the size of his eligible patients’ list.

Results

In the Firenze project, an invitation signed by the GP and the project co-ordinator attained a statistically significant higher participation (difference: 4.2%, χ2 = 7.42, P = 0.006). In Caltanissetta and Torino there was a significant increase of about 7% in the response rate to the postal reminder in the groups contacted by the GPs. No difference was observed in the Modena project between the two groups.

Conclusions

The main contributions of GP involvement can be: “cleaning up'’ the invitation lists, especially when computerized archives with the mammographic history of the target population are not available; increasing the women's participation by signing the invitation letter, by counseling and active participation in the invitation phase; co-operating in the reminder phase by recalling women non responders at first invitation. The offer of target payment had a certain impact on the screening uptake, but not easily distinguishable from GP signature of the invitation letter; further studies of appropriate design should be planned. Organizational factors, such as availability of a list of non-responders, might be crucial in order to enhance the effect of the GPs’ action.

The entity of thermal-crush-avulsion hand injury (hot-press roller burns) treated with fast acting debriding enzymes (nexobrid): literature review and report of first case

Hand burns are present in >60% of all burn cases and in fire mass casualty incidents even up to 100%. Most trauma and especially burns may be detrimental to the complex and delicate structures of the hand by direct injury, indirect BICS (Burn Induced Compartment Syndrome and interstitial high pressure) or by delayed or faulty treatment. BICS represents a special threat as the increasing swelling and oedema of the small diameter hand and forearm will exert pressure on the capillary/venous system, eventually ending in irreversible damage to the skin, nerves, muscle and vascular bed. Immediate release of constricting skin by incisional escharotomy and sometimes fasciotomy may arrest this vicious cycle: escharotomy is simple for experienced hand or burn surgeons, but they are not always present at the primary treatment site. The diagnosis of BICS is not simple either, as the direct measurement of interstitial/compartment pressure is rarely done. Burns caused by hot rollers such as industrial linen ironing machines are especially traumatic as besides the "simple" thermal burn, the hot rollers exert immense crushing pressure to the hand caught between the rollers. Over the last few years, several publications have described the role of a newly approved Bromelain derived enzymatic debriding agent (NexoBrid) for burns in general and hand burns in particular, and its ability to resolve or prevent BICS. We present a rare severe thermal/crush hand injury case where we were able to successfully treat the patient with NexoBrid enzymatic debridement-escharotomy.

Increased Il-8 Levels in the Cerebrospinal Fluid of Patients with Amyotrophic Lateral Sclerosis

Inflammation has been implicated in the pathogenesis of many neurodegenerative diseases. The chemokine IL-8 is thought to have a pathophysiological role in neurodegenerative diseases. IL-8 has recently been shown to induce death of primary cultured motor neurons in vitro. We determined IL-8 levels in the cerebrospinal fluid (CSF) from 38 patients with sporadic amyotrophic lateral sclerosis (ALS) compared to patients with other non-inflammatory neurological diseases (cerebrovascular disease, degenerative dementia, Parkinson's disease, compressive radiculo-myelopathy). Multiple sclerosis (MS) patients were used as positive controls. The levels of IL-8 in the CSF of ALS patients were significantly higher than those of patients with other, non-inflammatory neurological conditions and similar to those of MS patients. The only variable influencing IL-8 in ALS patients was sex, with higher levels in men than in women. The presence of the inflammatory cytokine IL-8 in the CSF of patients with ALS at the time of diagnosis strengthens the hypothesis of a role for this chemokine in neurodegenerative disorders.

Neuroimaging Changes in Menkes Disease, Part 2

This is the second part of a retrospective and review MR imaging study aiming to define the frequency rate, timing, imaging features, and evolution of gray matter changes in Menkes disease, a rare multisystem X-linked disorder of copper metabolism characterized by early, severe, and progressive neurologic involvement. According to our analysis, neurodegenerative changes and focal basal ganglia lesions already appear in the early phases of the disease. Subdural collections are less common than generally thought; however, their presence remains important because they might challenge the differential diagnosis with child abuse and might precipitate the clinical deterioration. Anecdotal findings in our large sample seem to provide interesting clues about the protean mechanisms of brain injury in this rare disease and further highlight the broad spectrum of MR imaging findings that might be expected while imaging a child with the suspicion of or a known diagnosis of Menkes disease.

Oncological and complication assessment of CO2 laser-assisted endoscopic surgery for T1-T2 glottic tumours: clinical experience

Several therapeutic options are used for treatment of early stage glottic carcinoma (Tis/T1/T2): open partial laryngectomy (OPL), radiotherapy and CO2 laser-assisted endoscopic surgery. Laser surgery has gradually gained approval in the management of laryngeal cancer. We present our experience in endoscopic laser surgery for early stage glottic carcinomas. This was a retrospective analysis of 72 patients with T1-T2 glottic cancer treated with laser cordectomy between 2006 and 2012. All patients had at least a 36-month follow-up period. Percentages for disease-specific survival, disease-free survival (DFS) and laryngeal preservation rates were 98.6%, 84.7% and 97.2% respectively. Considering neoplastic features that could predict long-term oncological outcome, tumoural involvement of anterior commissure and pathological staging (pT) significantly correlate with local recurrence (p = 0.021 and p = 0.035) and with a lowered DFS (p = 0.017 and p = 0.023). Other variables such as clinical staging, type of cordectomy, involvement of other structures and surgical margin status showed no significant impact on oncological endpoints. CO2 laser surgery is a reliable technique for T1-T2 glottic cancer considering oncological outcomes. The recurrence rate seems to be affected by involvement of anterior commissure and pT stage.

Open partial horizontal laryngectomies: is it time to adopt a modular form of consent for the intervention?

Nowadays, open partial horizontal laryngectomies (OPHLs) are well-established procedures for treatment of laryngeal cancer. Their uniqueness is the possibility to modulate the intervention intraoperatively, according to eventual tumour extension. An OPHL procedure is not easy to understand: there are several types of procedures and the possibility to modulate the intervention can produce confusion and lack of adherence to the treatment from the patient. Even if the surgery is tailored to a patient's specific lesion, a unified consent form that discloses any possible extensions, including a total laryngectomy, is still needed. We reviewed the English literature on informed consent, and propose comprehensive Information and Consent Forms for OPHLs. The Information Form is intended to answer any possible questions about the procedure, while remaining easy to read and understand for the patient. It includes sections on laryngeal anatomy and physiology, surgical aims and indications, alternatives to surgery, complications, and physiology of the operated larynx. The Consent Form is written in a "modular" way: the surgeon defines the precise extension of the lesion, chooses the best OPHL procedure and highlights all possible expected extensions specific for the patient. Our intention, providing these forms both in Italian and in English, is to optimise communication between the patient and surgeon, improving surgical procedure arrangements and preventing any possible misunderstandings and medico-legal litigation.

Parapharyngeal space tumours: video-assisted minimally invasive transcervical approach

The purpose of the present study was to evaluate the advantages of a video-assisted, minimally invasive transcervical approach to benign and malignant parapharyngeal space (PPS) tumours. Ten patients affected by benign and malignant PPS neoplasms underwent a combined transcervical and video-assisted minimally invasive approach, using Hopkins telescopes. We describe the operative technique and perform a review of the literature. Definitive histology revealed 3 pleomorphic adenomas, 2 schwannomas, 2 metastatic papillary thyroid carcinomas, one carcinoma ex pleomorphic adenoma, one cavernous haemangioma and one basal cell adenoma. Mean tumour size was 37.2 mm (range: 19-60). Operation time ranged from 75 min to 185 min (mean: 146.7). One case was converted to transcervical-transparotid approach. Patients were discharged on postoperative day 2-5. One patients presented hypoglossal nerve paresis. The minimally invasive video-assisted transcervical approach is safe and feasible for selected benign and malignant PPS tumours. Furthermore, it offers harmless dissection in a deep and narrow space, accurate haemostasis and continuous control of critical anatomic structures.

Neurodevelopmental profile in Angelman syndrome: more than low intelligence quotient

BACKGROUND

Angelman Syndrome (AS) is a rare neurodevelopment disorder resulting from deficient expression or function of the maternally inherited allele of UBE3A gene. The aim of the study is to attempt at providing a detailed definition of neurodevelopmental profile in AS, with particular regard to motor, cognitive, communicative, behavioural and neurovisual, features by using standardized instruments.

METHOD

A total of ten subjects aged from 5 to 11 years (4 males and 6 females) with molecular confirmed diagnosis of AS (7 15q11.2-q13 deletion and 3 UBE3A mutation) were enrolled in our study. All of them underwent an assessment protocol including neurological and neurovisual examination and the evaluation of motor (Gross Motor Function Measure Scale), cognitive (Griffiths Mental Development Scale and Uzgiris-Hunt Scale); adaptive (Vineland Adaptive Behavioural Scale); communication (MacArthur-Bates Communicative Development Inventory and video-recordings children's verbal expression), behavioural aspects (IPDDAG Scale) and neurovisual aspects.

RESULTS

All children presented motor function involvement. A severe cognitive impairment was detected with different profiles according to the test applied. In all cases, communicative disability (phonemic inventory, word/gesture comprehension and production) and symptoms of inattention disorder were revealed. Neurovisual impairment was characterized by refractive errors, fundus oculi anomalies, strabismus and/or oculomotor dysfunction.

CONCLUSION

AS presents a complex neurodevelopmental profile in which several aspects play a negative role in global development leading to a severe functional impairment. Intellectual disability is not the only component because neurovisual functions and behavioural disorders may worsen the global function and are needed of specific rehabilitation programs.

Effectiveness and tolerability of perampanel in children and adolescents with refractory epilepsies-An Italian observational multicenter study

PURPOSE

To evaluate the efficacy and tolerability of Perampanel (PER) in children and adolescents with refractory epilepsies in daily clinical practice conditions.

PATIENTS AND METHODS

This Italian multicenter retrospective observational study was performed in 16 paediatric epilepsy centres. Inclusion criteria were: (i) ≤18 years of age, (ii) history of refractory epilepsy, (iii) a follow-up ≥5 months of PER add-on therapy. Exclusion criteria were: (i) a diagnosis of primary idiopathic generalized epilepsy, (ii) variation of concomitant AEDs during the previous 4 weeks. Response was defined as a ≥50% reduction in monthly seizure frequency compared with the baseline.

RESULTS

62 patients suffering from various refractory epilepsies were included in this study: 53% were males, the mean age was 14.2 years (range 6-18 years), 8 patients aged <12 years. Mean age at epilepsy onset was 3.4 years and the mean duration of epilepsy was 10.8 years (range 1-16), which ranged from 2 seizures per-month up to several seizures per-day (mean number=96.5). Symptomatic focal epilepsy was reported in 62.9% of cases. Mean number of AEDs used in the past was 7.1; mean number of concomitant AEDs was 2.48, with carbamazepine used in 43.5% of patients. Mean PER daily dose was 7.1mg (2-12mg). After an average of 6.6 months of follow-up (5-13 months), the retention rate was 77.4% (48/62). The response rate was 50%; 16% of patients achieved ≥75% seizure frequency reduction and 5% became completely seizure free. Seizure aggravation was observed in 9.7% of patients. Adverse events were reported in 19 patients (30.6%) and led to PER discontinuation in 4 patients (6.5%). The most common adverse events were behaviour disturbance (irritability and aggressiveness), dizziness, sedation and fatigue.

CONCLUSION

PER was found to be a safe and effective treatment when used as adjunctive therapy in paediatric patients with uncontrolled epilepsy.

Cigarette toxicity triggers Leber's hereditary optic neuropathy by affecting mtDNA copy number, oxidative phosphorylation and ROS detoxification pathways

Leber's hereditary optic neuropathy (LHON), the most frequent mitochondrial disease, is associated with mitochondrial DNA (mtDNA) point mutations affecting Complex I subunits, usually homoplasmic. This blinding disorder is characterized by incomplete penetrance, possibly related to several genetic modifying factors. We recently reported that increased mitochondrial biogenesis in unaffected mutation carriers is a compensatory mechanism, which reduces penetrance. Also, environmental factors such as cigarette smoking have been implicated as disease triggers. To investigate this issue further, we first assessed the relationship between cigarette smoke and mtDNA copy number in blood cells from large cohorts of LHON families, finding that smoking was significantly associated with the lowest mtDNA content in affected individuals. To unwrap the mechanism of tobacco toxicity in LHON, we exposed fibroblasts from affected individuals, unaffected mutation carriers and controls to cigarette smoke condensate (CSC). CSC decreased mtDNA copy number in all cells; moreover, it caused significant reduction of ATP level only in mutated cells including carriers. This implies that the bioenergetic compensation in carriers is hampered by exposure to smoke derivatives. We also observed that in untreated cells the level of carbonylated proteins was highest in affected individuals, whereas the level of several detoxifying enzymes was highest in carriers. Thus, carriers are particularly successful in reactive oxygen species (ROS) scavenging capacity. After CSC exposure, the amount of detoxifying enzymes increased in all cells, but carbonylated proteins increased only in LHON mutant cells, mostly from affected individuals. All considered, it appears that exposure to smoke derivatives has a more deleterious effect in affected individuals, whereas carriers are the most efficient in mitigating ROS rather than recovering bioenergetics. Therefore, the identification of genetic modifiers that modulate LHON penetrance must take into account also the exposure to environmental triggers such as tobacco smoke.

Clinical dissection of childhood occipital epilepsy of Gastaut and prognostic implication

BACKGROUND AND PURPOSE

Our aim was to describe the clinical and electrical features and the long-term evolution of childhood occipital epilepsy of Gastaut (COE-G) in a cohort of patients and to compare long-term prognosis between patients with and without other epileptic syndromes.

METHODS

This was a retrospective analysis of the long-term outcome of epilepsy in 129 patients with COE-G who were referred to 23 Italian epilepsy centres and one in Austria between 1991 and 2004. Patients were evaluated clinically and with electroencephalograms for 10.1-23.0 years. The following clinical characteristics were evaluated: gender, patient age at seizure onset, history of febrile seizures and migraine, family history of epilepsy, duration and seizure manifestations, circadian distribution and frequency of seizures, history of medications including the number of drugs, therapeutic response and final outcome.

RESULTS

Visual hallucinations were the first symptom in 62% and the only manifestation in 38.8% of patients. Patients were subdivided into two groups: group A with isolated COE-G; group B with other epileptic syndromes associated with COE-G. The most significant (P < 0.05) difference concerned antiepileptic therapy: in group A, 45 children responded to monotherapy; in group B only 15 children responded to monotherapy. At the end of follow-up, the percentage of seizure-free patients was significantly higher in group A than in group B.

CONCLUSIONS

Childhood occipital epilepsy of Gastaut has an overall favourable prognosis and a good response to antiepileptic therapy with resolution of seizures and of electroencephalogram abnormalities. The association of typical COE-G symptoms with other types of seizure could be related to a poor epilepsy outcome.