Total sleep deprivation decreases saliva ghrelin levels in adolescents

Ghrelin, a regulator of food intake and energy expenditure, has been shown to be associated with insufficient sleep. The goal of the present study was to investigate the effect of a single night of total sleep deprivation on fasting saliva ghrelin and on nocturnal variation of saliva ghrelin concentration. A further aim of the study was to investigate the influence of body mass index on changes in saliva ghrelin levels. Altogether 35 adolescents (18 boys; age: 13.8 ± 1.14 years) were studied on two subsequent days (sleep and total sleep deprivation). Saliva samples were collected during the two experimental nights at 21:00 hours, 01:00 hours and 06:00 hours. Total-ghrelin concentration showed a continuous increase from the evening until 06:00 hours. This increase was blunted significantly (p = 0.003) by total sleep deprivation. Total-ghrelin level was significantly lower (p = 0.02) during total sleep deprivation at 06:00 hours (median 403.6 pg ml^-1 ; 95% confidence interval: 343.1-468.9 pg ml^-1 ) as compared with values during the sleep condition (median 471.2 pg ml^-1 ; 95% confidence interval: 205.4-1578.7 pg ml^-1 ). Acyl-ghrelin levels did not present any change at the three time points, and were not affected by total sleep deprivation. Stratifying the study population according to body mass index (normal weight and overweight/obese groups), the blunting effect of total sleep deprivation was more pronounced in the obese/overweight group (sleep: median 428.2 pg ml^-1 ; 95% confidence interval: 331.3-606.9 pg ml^-1 versus total sleep deprivation: median 333.1 pg ml^-1 ; 95% confidence interval: 261.5-412.9 pg ml^-1 ; p = 0.0479). Saliva total-ghrelin concentrations gradually increased during the night, and total sleep deprivation significantly blunted this increase. This blunting effect was mainly observed in subjects with overweight/obesity. The physiological and clinical implications of the present observation are to be clarified by further studies.

Trends in Prevalence and Severity of Pre/Perinatal Cerebral Palsy Among Children Born Preterm From 2004 to 2010: A SCPE Collaboration Study

Aim: To report on prevalence of cerebral palsy (CP), severity rates, and types of brain lesions in children born preterm 2004 to 2010 by gestational age groups.

Methods: Data from 12 population-based registries of the Surveillance of Cerebral Palsy in Europe network were used. Children with CP were eligible if they were born preterm (<37 weeks of gestational age) between 2004 and 2010, and were at least 4 years at time of registration. Severity was assessed using the impairment index. The findings of postnatal brain imaging were classified according to the predominant pathogenic pattern. Prevalences were estimated per 1,000 live births with exact 95% confidence intervals within each stratum of gestational age: ≤27, 28–31, 32–36 weeks. Time trends of both overall prevalence and prevalence of severe CP were investigated using multilevel negative binomial regression models.

Results: The sample comprised 2,273 children. 25.8% were born from multiple pregnancies. About 2-thirds had a bilateral spastic CP. 43.5% of children born ≤27 weeks had a high impairment index compared to 37.0 and 38.5% in the two other groups. Overall prevalence significantly decreased (incidence rate ratio per year: 0.96 [0.92–1.00[) in children born 32–36 weeks. We showed a decrease until 2009 for children born 28–31 weeks but an increase in 2010 again, and a steady prevalence (incidence rate ratio per year = 0.97 [0.92–1.02] for those born ≤27 weeks. The prevalence of the most severely affected children with CP revealed a similar but not significant trend to the overall prevalence in the corresponding GA groups. Predominant white matter injuries were more frequent in children born <32 weeks: 81.5% (≤27 weeks) and 86.4% (28–31 weeks), compared to 63.6% for children born 32–36 weeks.

Conclusion: Prevalence of CP in preterm born children continues to decrease in Europe excepting the extremely immature children, with the most severely affected children showing a similar trend.

The impact of disease and sociodemographic background on children suffering from cerebral palsy

Összefoglaló. Bevezetés: A kutatócsoport 99 fő, cerebralis paresisben (CP) szenvedő gyermek (8-18 éves) önállóan közölt életminőségét értékelte, és az eredményeket összehasonlította egy 237 fős kontrollcsoport adataival, amelyek hasonló életkorú, egészséges általános populációhoz tartozó gyermekektől származtak. Célkitűzés: A kutatás célja annak megismerése volt, hogy a CP-ben szenvedő gyermekek hogyan vélekednek egészségi állapotukról és társadalmi helyzetükről. Módszer: Életminőség-kérdőív alkalmazása. Betegségspecifikus és társadalmi-demográfiai mutatók mérése, kiértékelése. Eredmények: Az CP-ben szenvedő gyermekek és szüleik az egészséggel kapcsolatos életminőséget rosszabbnak ítélték meg, mint társaik. Eredményeink azt mutatják, hogy a női nem, a rosszabb motoros funkció és a komorbiditások (epilepszia, incontinentia és intellektuális károsodás) negatív hatású. A szülői vélemény alkalmas volt proxyjelentésként a korreláció mért erőssége miatt. Figyelemre méltó, hogy az agyi bénulás típusai közül az egyoldali spasticus CP-ben szenvedő gyermekek életminőség-értéke a legalacsonyabb. A válaszadók valószínűleg a test két oldala között lévő funkcionális különbséget érezték. A szellemi fogyatékosság a betegpopuláció több mint felénél fordult elő. Testvéreik között a mentális betegség 5,7-szer gyakoribb. A CP-s gyerekek családi környezete sokkal hátrányosabb volt, mint az egészséges gyermekeké. A kutatás eredményei alapján megállapítható, hogy a szülő alacsonyabb iskolai végzettsége és munkaerőpiaci inaktivitása, valamint az egyszülős család a CP-s gyerekeknél szignifikánsan magasabb arányban fordult elő, és ezek a tényezők negatív hatást gyakoroltak az életminőségre. Következtetés: A fogyatékkal élő gyermekek életminőségét a betegség és a szociodemográfiai környezet egyaránt befolyásolja. Orv Hetil. 2021; 162(7): 269-279.

SUMMARY

INTRODUCTION

Self-reported health-related quality of life (HRQoL) of 99 children (8-18 years) with cerebral palsy (CP) was assessed and compared with 237, age-matched healthy control children from the general population.

OBJECTIVE

The aim was to find out the opinions of children with CP about their health status and social condition.

METHOD

Assessment of quality of life questionnaire was carried out. Measurements of disease-specific and sociodemographic variables were done.

RESULTS

Children with CP and their parents rated HRQoL poorer than their counterparts. Our results show that female sex, worse gross motor function and comorbidities (epilepsy, incontinence and intellectual impairment) had negative impact. The parental opinion was suitable as proxy report because of the measured strength of the correlation. Among the types of CP, interestingly, children with unilateral spastic CP had the poorest HRQoL. They were likely to feel a functional difference between the two sides of the body. Intellectual disability occurred in more than half of our patient population. Among their siblings, mental illness is 5.7 times more common. The family environment was much more disadvantageous than in the case of healthy children. As our study shows, lower education, inactive status in the labour market and single-parent family occurred at a much higher rate and worsened the quality of life.

CONCLUSION

Quality of life of children with disability was influenced by both the sociodemographic background and the disease. Orv Hetil. 2021; 162(7): 269-279.

The usefulness of MRI Classification System (MRICS) in a cerebral palsy cohort

AIM

Our aim was to investigate perinatal and clinical factors associated with children with cerebral palsy (CP) using magnetic resonance imaging (MRI). The distribution of MRI patterns was based on the MRI classification system (MRICS). Associations between perinatal/clinical characteristics and MRI patterns were also investigated.

METHODS

A population-based cohort study was performed; those 257 children (58.0% male) were enrolled from our CP database who born between 1990 and 2015 in Southwest Hungary and had at least one MRI scan.

RESULTS

Brain maldevelopments were found in 18.7% of our patients, 83.7% of those born at term. Grey matter lesions were found in 19.8% of our patients, and 80.0% of those children were born at term. The rate of white matter injuries was the highest (35.4%); 69.0% of these patients were born before 37th week of gestation. MRI revealed no abnormalities in 13.6% of children with CP. The best values of gross/fine motor and cognitive function tests were found in children with normal MRI and with grey matter injuries. The prevalence of epilepsy was above 60% in every group with an abnormal MRI.

CONCLUSION

MRI results were conclusive in 86.4% of children with CP. It is highly encouraged to perform cranial MRI in every patient with CP.

Does Co-occurred Cerebral Palsy Change the Prognosis of West Syndrome?

AIM

We aimed to examine the occurrence of cerebral palsy (CP) in children with West syndrome (WS), to estimate the possible causative factors by analyzing the neuroimaging examinations of patients, to evaluate their cognitive/motor function and epileptic status and to compare the prognosis of children with double pathology of WS and CP and of those without CP.

METHODS

The clinical and magnetic resonance imaging (MRI) data of 62 patients with West syndrome were evaluated. A total of 39 of 62 patients (63%) suffered from CP (CP group). The non-CP group included 23 patients.

RESULTS

Abnormal MRI was found in 55/62 (89%) patients. Main anomalies were: brain malformation (21), hypoxic-ischemic encephalopathy (13), cerebrovascular insult (8), infection (7), and other anomalies (6). In the CP group, the most common MRI abnormalities included pre/perinatal hypoxia/ischemia, brain malformation, cerebrovascular insult, and infection. In the non-CP group, brain malformations were the most frequent. Significantly more negative MRIs were found in the non-CP group. More than 60% of the patients were severely cognitively impaired, almost 90% of them had CP. Not only the occurrence of intellectual disability was lower in the non-CP group, but its severity was milder as well. A total of 78% of the children with CP had a very severe motor disability. Fifty-four percent in the CP and 67% in the non-CP group had therapy-resistant epilepsy.

CONCLUSION

WS has an especially unfavorable prognosis: cerebral anomaly was confirmed in 89% of our patients. CP was present in almost two-thirds of the children with WS, most of them had severe cognitive and motor deficits.

[Epidemiology, cost and economic impact of cerebral palsy in Hungary]

Background and purpose

The purpose of our communication was to determine the total cost of cerebral paretic patients in Hungary between 0 and 18 years and to assess their impact on the national budget.

Methods

Based on the data of Borsod county we calculated the CP characteristics. The cost of CP was determined by routine care of individuals. Lost Parental Income and Tax were calculated on the basis of average earnings. The ratio of GDP, Health and Social Budget and Health Budget to CP is based on CP annual average cost and frequency. We have developed a repeatable computational model.

Results

Of the risk groups, premature birth (30.97%), low birth weight (29.64%), perinatal asphyxia (19.47%) were the most common. Source is unknown of 37.61% of the cases. CP prevalence was 2.1‰. The two-sided (59.7%) and the one-sided (19.0%) spastic pareses dominated. The most serious form is the two-sided spastic paresis (42.5% GMFCS 3-5 degrees). Epilepsy was 22.0%, incontinence was 27%, mental involvement was 46%. Care for one child up to 18 years of age costs an average of 73 million HUF (€ 251,724). The lost family income was 27.36 million HUF (€ 94,345), and lost tax and health care contributions were 14.46 million HUF (€ 49,862). Additionally, 0.525% of the GDP, 0.88% of the full health and social budget and 1.83% of direct medical costs were spent for CP families.

Conclusion

The cost of CP disease is significant. Costs can be reduced by improving primary prevention. From the perspective of the family and government, it is better to care for families so they can take care of their disabled children.

[The evaluation of paroxysmal events in neonates and infants]

Background and purpose

Differential diagnosis of neonatal and infantile seizures based only on inspection poses a challenge even for specialists. Aims - To investigate the evaluations of neonatal and infantile paroxysmal events based only on inspection. Research question - Is there any difference in the opinion of neonatologists, paediatric neurologists and neurologists about the assessment of common paroxysmal events in infancy?

Methods

Video recordings about paroxysmal movements of 15 neonates or infants (aged 2 days- 5 months) were displayed for 47 paediatric neurologists, 35 neonatologists and nurses working in Neonatal or Perinatal Intensive Care Units and 43 neurologists. They had to decide without knowing the past medical history or EEG results whether events presented were epileptic or nonepileptic in nature.

Results

Answers of neonatologists and paediatric neurologists were correct in 67% of cases (824/1230), no significant difference was found between their results. The largest uncertainty was in the judgement of discrete hand movements and very rapid clonus with epileptic origin, they were judged correctly by only one third of participants. The result of neurologists was only slightly, but not significantly different from that of paediatric neurologists.

Conclusion

In most cases, the correct diagnosis of neonatal and infantile paroxysmal events requires video-EEG recording. No significant difference was revealed between the evaluation of neonatologists and paediatric neurologists about the differential diagnosis of movements. The ongoing cooperation of paediatric neurologists and neurologists going back to several decades facilitates the shaping of a common perspective.

Epileptic seizure or not? Proportion of correct judgement based only on a video recording of a paroxysmal event

PURPOSE

Our study was intended to measure the proportion of correct seizure recognition among different medical and non-medical groups based on only a video recording.

METHODS

Video recordings about paroxysmal movements of 15 very young infants (2days - 5 months of age) were displayed for six groups: 159 1st-year medical students, 65 4-5th-year medical students, 52 paediatric residents, 18 paediatric neurologists from different European countries, 43 adult neurologists and 37 parents whose children were treated at our Department. All participants were asked to decide which recording they considered as of epileptic origin or a non-epileptic event. Correct answer rate (CAR) was calculated in each group for every video.

RESULTS

The average CAR was the lowest in the group of 1st-year medical students (36.6%), the best results were reached by paediatric neurologists (67.4%). The CAR was significantly different between the groups of 1st-year medical students and paediatric neurologists (p=0.02), and between the groups of 1st-year medical students and residents (p=0.045). The CAR of the most deceptive epileptic seizure was only 18.2%. The judgement of parents proved to be better than that of the 1st-year medical students.

CONCLUSIONS

Recognising epileptic seizures in very young infants without EEG is extremely inaccurate. Even trained paediatric neurologists were able to judge correctly the different movement types in only 67.4% of the cases. The role of education and experience is clearly indicated by the increase in CAR from 1st-year medical students through well-trained paediatric neurologists.

Relationship between sleep duration and childhood obesity: Systematic review including the potential underlying mechanisms

AIM

The prevalence of obesity is continually increasing worldwide. Determining risk factors for obesity may facilitate effective preventive programs. The present review focuses on sleep duration as a potential risk factor for childhood obesity. The aim is to summarize the evidence on the association of sleep duration and obesity and to discuss the underlying potential physiological and/or pathophysiological mechanisms.

DATA SYNTHESIS

The Ovid MEDLINE, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for papers using text words with appropriate truncation and relevant indexing terms. All studies objectively measuring sleep duration and investigating the association between sleep duration and obesity or factors (lifestyle and hormonal) possibly associated with obesity were included, without making restrictions based on study design or language. Data from eligible studies were extracted in tabular form and summarized narratively. After removing duplicates, 3540 articles were obtained. Finally, 33 studies (including 3 randomized controlled trials and 30 observational studies) were included in the review.

CONCLUSION

Sleep duration seems to influence weight gain in children, however, the underlying explanatory mechanisms are still uncertain. In our review only the link between short sleep duration and the development of insulin resistance, sedentarism and unhealthy dietary patterns could be verified, while the role of other mediators, such as physical activity, screen time, change in ghrelin and leptin levels, remained uncertain. There are numerous evidence gaps. To answer the remaining questions, there is a need for studies meeting high methodological standards and including a large number of children.

[EEG-based cerebral networks in 14 neurological disorders]

Background - Brain networks have not been systematically investigated yet in most neurological disorders. Purpose - To investigate EEG functional connectivity (EEGfC) networks in 14 neurological disorders. Patients - Potentially eligible patients were collected from clinical and EEG databases. All the available clinical data and EEG records were critically revised. All the patients who suffered of a single neurological disorder (out of the 14) and had a good quality EEG recording entered the study. Confoundig factors as comorbidity and CNS-active drug effects were eliminated as far as possible. EEG analysis - Three minutes of resting-state, waking EEG activity were selected for analysis. Current source density (CSD) values were computed for 2394 cortical voxels by Low Resolution Electromagnetic Tomography (LORETA). Thereafter, Pearson correlation coefficients were computed between all pairs of 23 cortical regions of interest (ROI) in each hemisphere (LORETA Source Correlation, LSC software). Computation was carried out for conventional EEG broad bands and very narrow bands (1 Hz bandwidth) between 1 and 25 Hz as well. Correlation coefficients of each group were statistically compared to our normative EEG (LSC) database by two-talied t-tests. Bonferroni-corrected p<0.05 values were accepted as statistically significant, and were graphically displayed as topographical networks. Results and conclusion - Group-specific networks were demonstrated. However, non-specific networks, charasteristic for most groups, were detected as well. Common finding were: decreased connectivity in the alpha band and increased connectivity in the delta, theta bands and upper-beta band. Decreased alpha-band connectivity presumably reflected primary lesional effects and on the other hand, non-specific vulnerability of "rich club connections". Increased connectivity in the slow bands presumably indicated adaptive-compensatory activity of brain homeostasis.

[INDIVIDUAL EVALUATION OF LORETA ABNORMALITIES IN IDIOPATHIC GENERALIZED EPILEPSY]

BACKGROUND

Contemporary neuroimaging methods disclosed structural and functional cerebral abnormalities in idiopathic generalized epilepsies (IGEs). However, individual electrical (EEG) abnormalities have not been evaluated yet in IGE patients.

METHODS

IGE patients were investigated in the drug-free condition and after 3-6 month of antiepileptic treatment. To estimate the reproducibility of qEEG variables a retrospective recruited cohort of IGE patients was investigated. 19-channel resting state EEG activity was recorded. For each patient a total of 2 minutes EEG activity was analyzed by LORETA (Low Resolution Electromagnetic Tomography). Raw LORETA values were Z-transformed and projected to a MRI template. Z-values outside within the [+3Z] to [-3Z] range were labelled as statistically abnormal.

RESULTS

1. In drug-free condition, 41-50% of IGE patients showed abnormal LORETA values. 2. Abnormal LORETA findings showed great inter-individual variability. 3. Most abnormal LORETA-findings were symmetrical. 4. Most maximum Z-values were localized to frontal or temporal cortex. 5. Succesfull treatment was mostly coupled with disappearence of LORETA-abnormality, persistent seizures were accompanied by persistent LORETA abnormality.

DISCUSSION

1. LORETA abnormalities detected in the untreated condition reflect seizure-generating property of the cortex in IGE patients. 2. Maximum LORETA-Z abnormalities were topographically congruent with structural abnormalities reported by other research groups. 3. LORETA might help to investigate drug effects at the whole-brain level.

Increased resting-state EEG functional connectivity in benign childhood epilepsy with centro-temporal spikes

PURPOSE

To explore intrahemispheric, cortico-cortical EEG functional connectivity (EEGfC) in benign childhood epilepsy with rolandic spikes (BECTS).

METHODS

21-channel EEG was recorded in 17 non-medicated BECTS children and 19 healthy controls. 180s of spike- and artifact-free activity was selected for EEGfC analysis. Correlation of Low Resolution Electromagnetic Tomography- (LORETA-) defined current source density time series were computed between two cortical areas (region of interest, ROI). Analyses were based on broad-band EEGfC results. Groups were compared by statistical parametric network (SPN) method. Statistically significant differences between group EEGfC values were emphasized at p<0.05 corrected for multiple comparison by local false discovery rate (FDR).

RESULTS

(1) Bilaterally increased beta EEGfC occurred in the BECTS group as compared to the controls. Greatest beta abnormality emerged between frontal and frontal, as well as frontal and temporal ROIs. (2) Locally increased EEGfC emerged in all frequency bands in the right parietal area.

CONCLUSIONS

Areas of increased EEGfC topographically correspond to cortical areas that, based on relevant literature, are related to speech and attention deficit in BECTS children.

Neurophysiology of juvenile myoclonic epilepsy: EEG-based network and graph analysis of the interictal and immediate preictal states

INTRODUCTION

The neuronal mechanisms of enduring seizure propensity and seizure precipitation in juvenile myoclonic epilepsy (JME) are not known. We investigated these issues, within the framework of the "network concept" of epilepsy.

METHODS

Design1: 19, unmedicated JME patients were compared with nineteen, age-, and sex-matched normal control persons (NC). A total of 120s, artifact-free, paroxysm-free, eyes-closed, resting state EEG background activity was analyzed for each person. Design2: interictal and immediate preictal periods of the JME patients were compared in order to explore interictal-preictal network differences. For both comparison designs, statistically significant differences of EEG functional connectivity (EEGfC), nodal and global graph parameters were evaluated.

MAIN RESULTS

Design1: maximum abnormalities were: increased delta, theta, alpha1 EEGfC and decreased alpha2 and beta EEGfC in the JME group as compared to the NC group, mainly among cortical areas that are involved in sensory-motor integration. Nodal degree and efficiency of three, medial, basal frontal nodes were greater in JME than in NC, in the alpha1 band. Design2: preictal delta EEGfC showed further increase in the above-mentioned areas, as compared to the interictal state.

DISCUSSION

Increased EEGfC indicates a hypercoupled state among the specified cortical areas. This interictal abnormality further increases in the preictal state. Nodal graph statistics indicates abnormal neuronal dynamics in the cortical area that is the ictal onset zone in JME.

SIGNIFICANCE

Interictal and preictal neuronal dysfunction has been described in terms of network dynamics and topography in JME patients. Forthcoming investigations of seizure precipitation and therapeutic drug effects are encouraged on this basis.

Trends in prevalence and characteristics of post-neonatal cerebral palsy cases: a European registry-based study

The present paper aims to analyze trends over time in prevalence of cerebral palsy of post-neonatal origin, to investigate whether changes are similar according to severity and to describe the disability profile by etiology. Post-neonatal cases, birth years 1976 to 1998, were identified from the Surveillance of Cerebral Palsy in Europe collaboration (19 population-based registries). A recognized causal event occurring between 28 days and 24 months of age was considered to define the cases. Trends in prevalence were explored using graphical methods (Lowess and Cusum control chart) and modeled with negative binomial regressions. Over the study period, 404 cases were identified as post-neonatal cases (5.5% of the total). Mean prevalence rate was 1.20 per 10,000 live births (95% CI [1.08-1.31]). A significant downward trend was observed (p=0.001), with an accentuated decrease in the 1990 s. The prevalence of severe cases which account for around one third of the total also significantly decreased over time (p<0.001). In 46% of cases, an infectious aetiology was reported; the corresponding prevalence significantly decreased since 1989. No significant decrease was observed for the rate of cases due to a vascular episode or of traumatic origin. Our results emphasize the need of large population-based surveillance systems to reliably monitor trends in prevalence in rare subgroups of children like those with acquired cerebral palsy. The decrease of the overall prevalence as well as those of the most severe cases may be partly due to public health actions targeted to prevent such events.

EEG-LORETA endophenotypes of the common idiopathic generalized epilepsy syndromes

OBJECTIVE

We tested the hypothesis that the cortical areas with abnormal local EEG synchronization are dissimilar in the three common idiopathic generalized epilepsy (IGE) phenotypes: IGE patients with absence seizures (ABS), juvenile myoclonic epilepsy (JME) and epilepsy with generalized tonic-clonic seizures exclusively (EGTCS).

PATIENTS AND METHODS

Groups of unmedicated ABS, JME and EGTCS patients were investigated. Waking EEG background activity (without any epileptiform potentials) was analyzed by a source localization method, LORETA (Low Resolution Electromagnetic Tomography). Each patient group was compared to a separate, age-matched group of healthy control persons. Voxel-based, normalized broad-band (delta, theta, alpha, and beta) and very narrow band (VNB, 1Hz bandwidth, from 1 to 25Hz) LORETA activity (=current source density, A/m(2)) were computed for each person. Group comparison included subtraction (average patient data minus average control data) and group statistics (multiple t-tests, where Bonferroni-corrected p<0.05 values were accepted as statistically significant).

RESULTS

Statistically not significant main findings were: overall increased delta and theta broad band activity in the ABS and JME groups; decrease of alpha and beta activity in the EGTCS group. Statistically significant main findings were as follows. JME group: bilaterally increased theta activity in posterior (temporal, parietal, and occipital) cortical areas; bilaterally increased activity in the medial and basal prefrontal area in the 8Hz VNB; bilaterally decreased activity in the precuneus, posterior cingulate and superior parietal lobule in the 11Hz and 21-22Hz VNBs. ABS group: bilaterally increased theta activity emerged in the basal prefrontal and medial temporal limbic areas. Decreased activity was found at 19-21Hz in the right postcentral gyrus and parts of the right superior and medial temporal gyri. EGTCS group: decreased activity was found in the frontal cortex and the postcentral gyrus at 10-11Hz, increased activity in the right parahippocampal gyrus at 16-18Hz.

DISCUSSION

Increased theta activity in the posterior parts of the cortex is the endophenotype for JME. Increased theta activity in the fronto-temporal limbic areas is the endophenotype for ABS. Statistically not significant findings might indicate diffuse biochemical abnormality of the cortex in JME and ABS.

SIGNIFICANCE

EEG-LORETA endophenotypes may correspond to the selective propensity to generate absence and myoclonic seizures in the ABS and JME syndromes.

EEG background activity is abnormal in the temporal and inferior parietal cortex in benign rolandic epilepsy of childhood: a LORETA study

INTRODUCTION

Benign rolandic epilepsy of childhood (BERS) is an epilepsy syndrome with presumably genetic-developmental etiology. The pathological basis of this syndrome is completely unknown. We postulated that a developmental abnormality presumably results in abnormal EEG background activity findings.

PATIENTS AND METHODS

20 children with typical BERS and an age- and sex-matched group of healthy control children underwent EEG recording and analysis. 60×2 s epochs of waking EEG background activity (without epileptiform potentials and artifacts) were analyzed in the 1-25 Hz frequency range, in very narrow bands (VNB, 1 Hz bandwidth). LORETA (Low Resolution Electromagnetic Tomography) localized multiple distributed sources of EEG background activity in the Talairach space. LORETA activity (current source density) was computed for 2394 voxels and 25 VNBs. Normalized LORETA data were processed to voxel-wise comparison between the BERS and control groups. Bonferroni-corrected p<0.05 Student's t-values were accepted as statistically significant.

RESULTS

Increased LORETA activity was found in the BERS group (as compared to the controls) in the left and right temporal lobes (fusiform gyri, posterior parts of the superior, middle and inferior temporal gyri) and in the angular gyri in the parietal lobes, in the 4-6 Hz VNBs, mainly at 5 Hz.

DISCUSSION

(1) Areas of abnormal LORETA activity exactly correspond to the temporal and parietal cortical areas that are major components of the Mirsky attention model and also the perisylvian speech network. Thus the LORETA findings may correspond to impaired attention and speech in BERS patients. (2) The LORETA findings may contribute to delineating the epileptic network in BERS.

SIGNIFICANCE

The novel findings may contribute to investigating neuropsychological disturbances and organization of the epileptic network in BERS.

[Anti-NMDA-receptor encephalitis: description of the syndrome in connection with the first Hungarian patient]

In the majority of cases, anti-NMDA (N-methyl-D-aspartate) receptor encephalitis is a severe, but treatable disorder, therefore early diagnosis and adequate therapy are very important. It should be suspected in children and young women, who develop acute psychiatric symptoms and seizures. During the course of the disease severe encephalopathy, agitation, hallucinations, orofacial dyskinesias, prolonged cognitive disturbance, autonomic symptoms can be observed and akinetic mutism develops. EEG shows diffuse slowing. Brain MRI is normal or unspecific. Elevated protein, pleiocytosis and oligoclonal bands can be present in the CSF Detection of NMDA-receptor antibodies in sera or CSF confirms diagnosis. We present the case of a 15-year-old girl, who fully recovered within two months after steroid treatment and repeated plasma exchange. Ovarian teratoma has not been detected.

Transverse myelitis as a rare, serious complication of Mycoplasma pneumoniae infection

We report on the first published case of a Mycoplasma pneumoniae-associated transverse myelitis appearing in childhood and leading to persistent paraplegia and bowel and bladder dysfunctions. Magnetic resonance imaging of the spinal cord indicated extensive transverse myelitis extending from T(5)-T(12). A repeated scan established spinal cord atrophy in the affected area. Various therapies (methylprednisolone pulse therapy, plasmapheresis, and roxythromycine) produced no clinical effect.

[Mental retardation in childhood. The prevalence of informative morphogenetic variants]

The authors observed the prevalence of informative morphogenetic variants among mentally retarded children. In their retrospective examination of a 4-years period, they included 135 hospitalized children and analysed their clinical epidemiological and dysmorphic profiles. In their descriptive analysis they found ear abnormalities and abnormal head circumference as the most common dysmorphic sings among mentally retarded children, and they emphasize the highly different importance and predictive-diagnostic value of minor malformations and phenogenetic variants.

Ultrasound-guided, intraglandular injection of botulinum toxin A in children suffering from excessive salivation

Background: The aim of this study was to describe the authors' minimally invasive procedure developed to significantly decrease excessive salivation in children suffering from chronic neurological diseases, using botulinum toxin A.

Objective: Ultrasound-guided, intraglandular injection of botulinum toxin blocks the parasympathetic innervation of salivary glands, resulting in a temporary decrease in saliva production and improved quality of life, lasting about three to four months.

Materials and methods: Prior to introducing the method into clinical practice, animal experiments were conducted in order to verify the lack of histological changes three months following botulinum toxin administration. Twenty-one children were included in the clinical study, with ages ranging from two and a half to 14 years.

Results: The animal studies did not reveal any histological changes three months after botulinum toxin administration. Although botulinum toxin A proved to be ineffective in a single case, the majority of the other 20 patients responded well, with a highly significant reduction of their symptoms. The parents of 18 responder children requested repeated treatment with botulinum toxin A. However, two families refused to be further involved in the study, despite good results. The protein content of saliva, regulated by sympathetic innervation, was not affected by the treatment.

Conclusion: This minimally invasive method, applied repeatedly three to four times a year, may be a viable alternative to surgical procedures such as submandibular duct relocation, duct ligature or nervus tympanicus neurectomy.

Lamotrigine decreases EEG synchronization in a use-dependent manner in patients with idiopathic generalized epilepsy

OBJECTIVE

To investigate the quantitative EEG effects of lamotrigine (LTG) monotherapy.

HYPOTHESIS

LTG was predicted to decrease thalamo-cortical neuronal synchronization in idiopathic generalized epilepsy (IGE).

METHODS

Waking EEG background activity of 19 IGE patients was investigated before treatment and in the course of LTG monotherapy. Raw absolute power (RAP), raw percent power (RRP), and raw mean frequency (RMF) were computed for 19 electrodes and four frequency bands (delta=1.5-3.5Hz, theta=3.5-7.5Hz, alpha=7.5-12.5Hz, and beta=12.5-25.0Hz). Inter- and intrahemispheric coherence was computed for eight electrode pairs and the four frequency bands. In addition, scalp-averages were calculated for each variable. Group differences were computed by means of nonparametric statistics including correction for multiple comparisons.

RESULTS

Main results were decreased delta and theta RAP (p<0.05 for scalp-averages). LTG compressed the delta, theta, and alpha RAP datasets, reducing the upper limit of the scatter in particular. Spearman r-values indicated marked correlation between the starting values (RAPuntreated) and the LTG-related decrease (RAPtreated-RAPuntreated) in three bands: delta (r=-0.72; p=0.0005), theta (r=-0.59; p=0.007), and alpha (r=-0.61; p=0.006). Thus, the greater the baseline neuronal synchronization, the marked the dampening effect of LTG on it. The remaining findings were decreased theta RRP, theta RMF, and increased alpha RMF (p<0.05 for scalp-averages). The electrode-related changes were small but topographically consistent across the 19 electrode sites. LTG did not affect coherence.

CONCLUSIONS

1. LTG partially normalized the spectral composition of EEG background activity. LTG decreased pathological thalamo-cortical synchronization in use-dependent manner. 2. LTG did not cause quantitative EEG alterations suggesting worsening of the physiological brain functions. Instead, its profile suggested a mild psychostimulant effect.

SIGNIFICANCE

The results contribute to the understanding of the effect of LTG at the network level.

Quantitative EEG effects of carbamazepine, oxcarbazepine, valproate, lamotrigine, and possible clinical relevance of the findings

Quantitative EEG (QEEG) effects of therapeutic doses of carbamazepine (CBZ), oxcarbazepine (OXC), valproate (VA) and lamotrigine (LA) monotherapy were investigated in patients with beginning epilepsy. Baseline waking EEG (EEG1) was recorded in the untreated state, the second EEG (EEG2) was done after 8 weeks of reaching the therapeutic dose. Left occipital data were used for analysis. QEEG target parameters were absolute band-power (delta: AD, theta: AT, alpha: AA, beta: AB), and alpha mean frequency (AMF). Group effects (untreated versus treated condition in the CBZ, VA, OXC, LA groups) were computed for each target parameter. One group with benign rolandic epilepsy remained untreated for clinical reasons and served to estimate the QEEG test-retest differences. In addition, the individual QEEG response to each drug was calculated as (EEG2-EEG1).

RESULTS

statistically significant (p<0.05) group differences indicated the QEEG domain systematically affected by the drugs. CBZ caused AT increase and AMF decrease. OXC caused AMF decrease. VA and LA did not decrease AMF (LA even increased it), but reduced broad-band power. Individual power and AMF changes showed considerable variability in each group. >0.5 Hz AMF decrease (that was reported to predict cognitive impairment in prior studies) occurred in 10/41 patients in the CBZ group but never in the OXC, VA, LA groups. The results may be utilized in planning further studies addressing the relationship between antiepileptic drugs and their CNS effects. In addition, the relationship of AED-related cognitive impairment and AMF changes was discussed.

Tel Hashomer camptodactyly syndrome: 12-year follow-up of a Hungarian patient and review

Tel Hashomer camptodactyly syndrome (THCS) was diagnosed in a 4-month-old boy whom we have followed for 12 years. In addition to the characteristic clinical findings, he had preductal coarctation of the aorta, persistent ductus arteriosus, and multiple ventricular septal defects. The electron-microscopic evaluation of his muscle biopsy showed anomalies of the sarcoplasmic reticulum and mitochondria; the organization of the myofibrils was normal. The morphological findings suggested primary or secondary involvement of neuromuscular signal transduction and involvement of mitochondria in the development of the myopathy in this child.

Maternally inherited deafness and unusual phenotypic manifestations associated with A3243G mitochondrial DNA mutation

The mitochondrial DNA A3243G transition is a fairly common mutation which often associates with a MELAS (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) phenotype, however, a broad variety in the associated clinical picture has also been described. The patient reported here developed a generalized seizure at age 12, which was followed by bilateral hearing loss and occasional fatigue. The maternal inheritance pattern of hearing loss pointed to a possible mitochondrial origin, which was confirmed by molecular analysis of the mitochondrial DNA, revealing a heteroplasmic A3243G transition. Interestingly, muscle biopsy showed ragged-red fibers in the proband, which is unusual in the deafness-associated forms of this mitochondrial disorder. In addition to hearing impairment in four generations of the family, fatal cerebral embolization in the mother and fatal heart attack in the maternal grandmother (both at age 33) also occurred. On the contrary, diabetes, which usually accompanies the hearing loss variant, was specifically absent in all generations. The unusual manifestations associated with this mutation somewhat differentiate this family from the already known variants.

[DOOR (deafness, onychodystrophy, osteodystrophy, mental retardation) syndrome]

Authors highlight the difficulties of syndrome identification through reporting the first case of DOOR syndrome in Hungary (the 28th case worldwide). The awareness and appropriate weighing of the importance of vestigial nails (onychodystrophy) was crucial for the correct diagnosis. Based on the normal level of 2-oxoglutarate excretion, the patient can be categorized as type 2. This is associated with better survival, which does not mean a substantial difference in quality of life. Although, prenatal diagnosis is not possible at present, knowledge of the enzyme defect and detection of the reduced activity of the 2-oxoglutarate dehydrogenase E1 component may provide an opportunity. If parents opt to have another child, a 25% risk is to be taken into account.

[Mutational analysis of the MECP2 gene by direct sequencing in Hungarian patients with Rett syndrome]

INTRODUCTION

Rett syndrome is an X-linked neurodevelopmental disorder characterized by loss of acquired skills and stereotypical hand movements. Mutations in the gene encoding methyl-CpG-binding protein 2 have been identified as cause of Rett syndrome in 1999.

AIM

The authors initialized mutation screening of this gene in Hungarian patients identified on the base of clinical manifestation in various institutes. So far 25 patients were examined who were supposed to have Rett syndrome.

METHOD

Total genomic DNA was extracted from peripheral blood with routine desalting method for mutation analysis. The three coding regions of the gene were amplified with primer pairs described. The PCR products were analysed by direct sequencing.

RESULTS

Mutations in methyl-CpG-binding protein 2 gene were found in 17/25 cases (68%). This rate of mutation among Rett patients corresponds well with the findings of other studies. Two novel mutations were found. In the first patient whose history was characterized by a slower than normal progression, a G insertion at the base position 276 of exon 3 was detected, while in the second child a double deletion (191, and 9 bases, resp.) in exon 4 was identified.

[Refsum disease]

For the first time in literature the authors interpret the pathography of Refsum's disease, in the case of their patient, as pseudo-hypervitaminosis A. The biochemical basis of the clinical picture is a defect in the activity of phytanic-acid-alpha-hydrolase belonging to the peroxisomal system. As a consequence, phytanic acid accumulates in the serum and in the parenchymal tissues. Retinol, an alcohol with high molecular weight, is a natural ligand of nuclear RXR (retinoid-X-receptor), which plays an important role in the regulation of peroxisoma synthesis. In Refsum's disease the phytanic acid accumulated because of the enzyme defect competes with the biotransformation derivates (all-trans-retinoic acid, 9-cis-retinoic acid) of the all-trans-retinol (vitamin A) for the nuclear RX receptor binding sites, and as a very potent receptoractivator it causes the intestinal symptoms of hypervitaminosis A. The authors review the procedure of fatty-acid chromatography necessary for the establishment of the diagnosis and discuss--in addition to dietary restrictions--recent therapeutic possibilities, like plasmapheresis, cascade filtration, lipapheresis and oral batylalcohol treatment.

[Hallervorden-Spatz disease]

Based on the history of a 5-year-old boy, the clinical picture and the natural history of Hallervorden-Spatz disease are reviewed. In the past, the diagnosis of Hallervorden-Spatz disease has usually been made only post mortem. In the T2 weighted MRI images "eye of the tiger" sign is seen. This is due to iron-accumulation in the pallidum and it makes the earlier, in vivo diagnosis of the disease possible.

[PEHO syndrome (progressive encephalopathy, edema, hypsarrhythmia. optic atrophy)]

The authors report the case of a now 2-year-old boy with PEHO syndrome. The syndrome is rare and it has not been published yet in Hungary. The syndrome was named after the first letters of its main characteristic signs: progressive encephalopathy, edema, hypsarrhythmia and optic atrophy. The aetiology of the syndrome is still unknown. Autosomal recessive inheritance is likely. The prognosis is poor. Intractable infantile spasms and the arrest of the psychomotoric and mental development can be expected.

[A case of herpes simplex encephalitis requiring surgical management]

The authors report about surgical treatment of herpes simplex encephalitis, although conservative management of this disease is the method of choice in the first place. They draw a lesson from this case that certain cases of large space occupying lesions of infectious origin leading to brain stem compression may require surgical management, even if they customary treatment is conservative.

[Glucosylated proteins and perinatal growth]

The concentration of HbA1c and glycosylated serum proteins were measured colorimetrically in 30 and 29 newborn infants of various gestational age, at the postnatal age of 0-24 hrs and 19-23 days, respectively. No relationship was found either between the maturity and the prenatal and early postnatal growth of the studied infants or the concentration of glycosylated haemoglobin and serum proteins.

[Concentration of C-reactive protein in neonatal pathology]

C-reactive protein concentration was measured in 56 preterm and 61 full term newborn infants with various pathology, at the postnatal age of 0-24 hrs and 1, 2, 3, 4 weeks. One third of all study babies had an increased (greater than 10 mg/l) CRP level measured within 24 hrs of birth. On the first day, CRP concentration in neonates with a pronounced perinatal asphyxia was as high as in those who suffered from perinatal infection. Further postnatal changes in CRP level need individual evaluation in every case, considering the diagnosis, clinical course and treatment. In connection with the results the clinical usefulness of CRP determinations in neonatal medicine is shortly discussed.