1
|
Eyal AD, Eyal S. Increasing challenges to trial recruitment: Is it time to change the inclusion criteria for investigational compounds, not just for study participants? Epilepsia 2024; 65:1907-1915. [PMID: 38713479 DOI: 10.1111/epi.17978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/28/2024] [Indexed: 05/08/2024]
Affiliation(s)
| | - Sara Eyal
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
2
|
Nguyen TD, Ishibashi M, Sinha AS, Watanabe M, Kato D, Horiuchi H, Wake H, Fukuda A. Astrocytic NKCC1 inhibits seizures by buffering Cl - and antagonizing neuronal NKCC1 at GABAergic synapses. Epilepsia 2023; 64:3389-3403. [PMID: 37779224 DOI: 10.1111/epi.17784] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE A pathological excitatory action of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA) has been observed in epilepsy. Blocking the Cl- importer NKCC1 with bumetanide is expected to reduce the neuronal intracellular Cl- concentration ([Cl- ]i ) and thereby attenuate the excitatory GABA response. Accordingly, several clinical trials of bumetanide for epilepsy were conducted. Although NKCC1 is expressed in both neurons and glial cells, an involvement of glial NKCC1 in seizures has not yet been reported. Astrocytes maintain high [Cl- ]i with NKCC1, and this gradient promotes Cl- efflux via the astrocytic GABAA receptor (GABAA R). This Cl- efflux buffers the synaptic cleft Cl- concentration to maintain the postsynaptic Cl- gradient during intense firing of GABAergic neurons, thereby sustaining its inhibitory action during seizure. In this study, we investigated the function of astrocytic NKCC1 in modulating the postsynaptic action of GABA in acute seizure models. METHODS We used the astrocyte-specific conditional NKCC1 knockout (AstroNKCC1KO) mice. The seizurelike events (SLEs) in CA1 pyramidal neurons were triggered by tetanic stimulation of stratum radiatum in acute hippocampus slices. The SLE underlying GABAA R-mediated depolarization was evaluated by applying the GABAA R antagonist bicuculline. The pilocarpine-induced seizure in vivo was monitored in adult mice by the Racine scale. The SLE duration and tetanus stimulation intensity threshold and seizure behavior in AstroNKCC1KO mice and wild-type (WT) mice were compared. RESULTS The AstroNKCC1KO mice were prone to seizures with lower threshold and longer duration of SLEs and larger GABAA R-mediated depolarization underlying the SLEs, accompanied by higher Racine-scored seizures. Bumetanide reduced these indicators of seizure in AstroNKCC1KO mice (which still express neuronal NKCC1), but not in the WT, both in vitro and in vivo. SIGNIFICANCE Astrocytic NKCC1 inhibits GABA-mediated excitatory action during seizures, whereas neuronal NKCC1 has the converse effect, suggesting opposing actions of bumetanide on these cells.
Collapse
Affiliation(s)
- Trong Dao Nguyen
- Department of Neurophysiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masaru Ishibashi
- Department of Neurophysiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Adya Saran Sinha
- Department of Neurophysiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Miho Watanabe
- Department of Neurophysiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daisuke Kato
- Department of Anatomy and Molecular Cell Biology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Horiuchi
- Department of Anatomy and Molecular Cell Biology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Wake
- Department of Anatomy and Molecular Cell Biology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsuo Fukuda
- Department of Neurophysiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
3
|
Rao S, Farhat A, Rakshasbhuvankar A, Athikarisamy S, Ghosh S, Nagarajan L. Effects of bumetanide on neonatal seizures: A systematic review of animal and human studies. Seizure 2023; 111:206-214. [PMID: 37690372 DOI: 10.1016/j.seizure.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Bumetanide, an inhibitor of the sodium-potassium-chloride cotransporter-1, has been suggested as an adjunct to phenobarbital for treating neonatal seizures. METHODS A systematic review of animal and human studies was conducted to evaluate the efficacy and safety of bumetanide for neonatal seizures. PubMed, Embase, CINAHL and Cochrane databases were searched in March 2023. RESULTS 26 animal (rat or mice) studies describing 38 experiments (28 in-vivo and ten in-vitro) and two human studies (one RCT and one open-label dose-finding) were included. The study designs, methods to induce seizures, bumetanide dose, and outcome measures were heterogeneous, with only 4/38 experiments being in animal hypoxia/ischaemia models. Among 38 animal experiments, bumetanide was reported to have antiseizure effects in 21, pro-seizure in six and ineffective in 11. The two human studies (n = 57) did not show the benefits of bumetanide as an add-on agent to phenobarbital in their primary analyses, but one study reported benefit on post-hoc analysis. Overall, hearing impairment was detected in 5/37 surviving infants in the bumetanide group vs. 0/13 in controls. Four of the five infants with hearing impairment had received aminoglycosides concurrently. Other adverse effects reported were diuresis, mild-to-moderate dehydration, hypotension, and electrolyte disturbances. The studies did not report on long-term neurodevelopment. The certainty of the evidence was very low. CONCLUSION Animal data suggest that bumetanide has inconsistent effects as an antiseizure medication in neonates. Data from human studies are scarce and raise some concerns regarding ototoxicity when given with aminoglycosides. Well conducted studies in animal models of hypoxic-ischaemic encephalopathy are urgently needed. Future RCTs, if conducted in human neonates, should have an adequate sample size, assess neurodevelopment, minimize using aminoglycosides, be transparent about the potential ototoxicity in the parent information sheet, conduct early hearing tests and have trial-stopping rules that include hearing impairment as an outcome.
Collapse
Affiliation(s)
- Shripada Rao
- Neonatal Intensive Care Unit, King Edward Memorial and Perth Children's Hospitals, Perth, Australia; Paediatric Division, Medical School, University of Western Australia, Perth, Australia.
| | - Asifa Farhat
- General Paediatrics, Perth Children's Hospital, Perth, Australia
| | - Abhijeet Rakshasbhuvankar
- Neonatal Intensive Care Unit, King Edward Memorial and Perth Children's Hospitals, Perth, Australia; Paediatric Division, Medical School, University of Western Australia, Perth, Australia
| | - Sam Athikarisamy
- Neonatal Intensive Care Unit, King Edward Memorial and Perth Children's Hospitals, Perth, Australia; Paediatric Division, Medical School, University of Western Australia, Perth, Australia
| | - Soumya Ghosh
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Australia; Centre for Neuromuscular and Neurological Disorders, Perron Institute, University of Western Australia, Perth, Australia
| | - Lakshmi Nagarajan
- Paediatric Division, Medical School, University of Western Australia, Perth, Australia; Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Australia
| |
Collapse
|
4
|
Perucca E, White HS, Bialer M. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: II. Treatments in Clinical Development. CNS Drugs 2023; 37:781-795. [PMID: 37603261 PMCID: PMC10501930 DOI: 10.1007/s40263-023-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/22/2023]
Abstract
The inhibitory neurotransmitter γ-aminobutyric acid (GABA) plays an important role in the modulation of neuronal excitability, and a disruption of GABAergic transmission contributes to the pathogenesis of some seizure disorders. Although many currently available antiseizure medications do act at least in part by potentiating GABAergic transmission, there is an opportunity for further research aimed at developing more innovative GABA-targeting therapies. The present article summarises available evidence on a number of such treatments in clinical development. These can be broadly divided into three groups. The first group consists of positive allosteric modulators of GABAA receptors and includes Staccato® alprazolam (an already marketed benzodiazepine being repurposed in epilepsy as a potential rescue inhalation treatment for prolonged and repetitive seizures), the α2/3/5 subtype-selective agents darigabat and ENX-101, and the orally active neurosteroids ETX155 and LPCN 2101. A second group comprises two drugs already marketed for non-neurological indications, which could be repurposed as treatments for seizure disorders. These include bumetanide, a diuretic agent that has undergone clinical trials in phenobarbital-resistant neonatal seizures and for which the rationale for further development in this indication is under debate, and ivermectin, an antiparasitic drug currently investigated in a randomised double-blind trial in focal epilepsy. The last group comprises a series of highly innovative therapies, namely GABAergic interneurons (NRTX-001) delivered via stereotactic cerebral implantation as a treatment for mesial temporal lobe epilepsy, an antisense oligonucleotide (STK-001) aimed at upregulating NaV1.1 currents and restoring the function of GABAergic interneurons, currently tested in a trial in patients with Dravet syndrome, and an adenoviral vector-based gene therapy (ETX-101) scheduled for investigation in Dravet syndrome. Another agent, a subcutaneously administered neuroactive peptide (NRP2945) that reportedly upregulates the expression of GABAA receptor α and β subunits is being investigated, with Lennox-Gastaut syndrome and other epilepsies as proposed indications. The diversity of the current pipeline underscores a strong interest in the GABA system as a target for new treatment development in epilepsy. To date, limited clinical data are available for these investigational treatments and further studies are required to assess their potential value in addressing unmet needs in epilepsy management.
Collapse
Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), Melbourne Brain Centre, The University of Melbourne, 245 Burgundy Street, Melbourne, VIC, 3084, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Meir Bialer
- Faculty of Medicine, Institute of Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
5
|
Welzel B, Johne M, Löscher W. Bumetanide potentiates the anti-seizure and disease-modifying effects of midazolam in a noninvasive rat model of term birth asphyxia. Epilepsy Behav 2023; 142:109189. [PMID: 37037061 DOI: 10.1016/j.yebeh.2023.109189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/12/2023]
Abstract
Birth asphyxia and the resulting hypoxic-ischemic encephalopathy (HIE) are highly associated with perinatal and neonatal death, neonatal seizures, and an adverse later-life outcome. Currently used drugs, including phenobarbital and midazolam, have limited efficacy to suppress neonatal seizures. There is a medical need to develop new therapies that not only suppress neonatal seizures but also prevent later-life consequences. We have previously shown that the loop diuretic bumetanide does not potentiate the effects of phenobarbital in a rat model of birth asphyxia. Here we compared the effects of bumetanide (0.3 or 10 mg/kg i.p.), midazolam (1 mg/kg i.p.), and a combination of bumetanide and midazolam on neonatal seizures and later-life outcomes in this model. While bumetanide at either dose was ineffective when administered alone, the higher dose of bumetanide markedly potentiated midazolam's effect on neonatal seizures. Median bumetanide brain levels (0.47-0.53 µM) obtained with the higher dose were in the range known to inhibit the Na-K-Cl-cotransporter NKCC1 but it remains to be determined whether brain NKCC1 inhibition was underlying the potentiation of midazolam. When behavioral and cognitive alterations were examined over three months after asphyxia, treatment with the bumetanide/midazolam combination, but not with bumetanide or midazolam alone, prevented impairment of learning and memory. Furthermore, the combination prevented the loss of neurons in the dentate hilus and aberrant mossy fiber sprouting in the CA3a area of the hippocampus. The molecular mechanisms that explain that bumetanide potentiates midazolam but not phenobarbital in the rat model of birth asphyxia remain to be determined.
Collapse
Affiliation(s)
- Björn Welzel
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Marie Johne
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany.
| |
Collapse
|
6
|
Welzel B, Schmidt R, Kirchhoff L, Gramer M, Löscher W. The loop diuretic torasemide but not azosemide potentiates the anti-seizure and disease-modifying effects of midazolam in a rat model of birth asphyxia. Epilepsy Behav 2023; 139:109057. [PMID: 36586153 DOI: 10.1016/j.yebeh.2022.109057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
Loop diuretics such as furosemide and bumetanide, which act by inhibiting the Na-K-2Cl cotransporter NKCC2 at the thick ascending limb of the loop of Henle, have been shown to exert anti-seizure effects. However, the exact mechanism of this effect is not known. For bumetanide, it has been suggested that inhibition of the NKCC isoform NKCC1 in the membrane of brain neurons may be involved; however, NKCC1 is expressed by virtually all cell types in the brain, which makes any specific targeting of neuronal NKCC1 by bumetanide impossible. In addition, bumetanide only poorly penetrates the brain. We have previously shown that loop diuretics azosemide and torasemide also potently inhibit NKCC1. In contrast to bumetanide and furosemide, azosemide and torasemide lack a carboxylic group, which should allow them to better penetrate through biomembranes by passive diffusion. Because of the urgent medical need to develop new treatments for neonatal seizures and their adverse outcome, we evaluated the effects of azosemide and torasemide, administered alone or in combination with phenobarbital or midazolam, in a rat model of birth asphyxia and neonatal seizures. Neither diuretic suppressed the seizures when administered alone but torasemide potentiated the anti-seizure effect of midazolam. Brain levels of torasemide were below those needed to inhibit NKCC1. In addition to suppressing seizures, the combination of torasemide and midazolam, but not midazolam alone, prevented the cognitive impairment of the post-asphyxial rats at 3 months after asphyxia. Furthermore, aberrant mossy fiber sprouting in the hippocampus was more effectively prevented by the combination. We assume that either an effect on NKCC1 at the blood-brain barrier and/or cells in the periphery or the NKCC2-mediated diuretic effect of torasemide are involved in the present findings. Our data suggest that torasemide may be a useful option for improving the treatment of neonatal seizures and their adverse outcome.
Collapse
Affiliation(s)
- Björn Welzel
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Ricardo Schmidt
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Larsen Kirchhoff
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | - Martina Gramer
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | - Wolfgang Löscher
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany.
| |
Collapse
|
7
|
Bryson A, Reid C, Petrou S. Fundamental Neurochemistry Review: GABA A receptor neurotransmission and epilepsy: Principles, disease mechanisms and pharmacotherapy. J Neurochem 2023; 165:6-28. [PMID: 36681890 DOI: 10.1111/jnc.15769] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 01/23/2023]
Abstract
Epilepsy is a common neurological disorder associated with alterations of excitation-inhibition balance within brain neuronal networks. GABAA receptor neurotransmission is the most prevalent form of inhibitory neurotransmission and is strongly implicated in both the pathophysiology and treatment of epilepsy, serving as a primary target for antiseizure medications for over a century. It is now established that GABA exerts a multifaceted influence through an array of GABAA receptor subtypes that extends far beyond simply negating excitatory activity. As the role of GABAA neurotransmission within inhibitory circuits is elaborated, this will enable the development of precision therapies that correct the network dysfunction underlying epileptic pathology.
Collapse
Affiliation(s)
- Alexander Bryson
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Christopher Reid
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Steven Petrou
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia.,Praxis Precision Medicines, Inc., Cambridge, Massachusetts, USA
| |
Collapse
|
8
|
Delpire E, Ben-Ari Y. A Wholistic View of How Bumetanide Attenuates Autism Spectrum Disorders. Cells 2022; 11:cells11152419. [PMID: 35954263 PMCID: PMC9367773 DOI: 10.3390/cells11152419] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 01/27/2023] Open
Abstract
The specific NKCC1 cotransporter antagonist, bumetanide, attenuates the severity of Autism Spectrum Disorders (ASD), and many neurodevelopmental or neurodegenerative disorders in animal models and clinical trials. However, the pervasive expression of NKCC1 in many cell types throughout the body is thought to challenge the therapeutic efficacy of bumetanide. However, many peripheral functions, including intestinal, metabolic, or vascular, etc., are perturbed in brain disorders contributing to the neurological sequels. Alterations of these functions also increase the incidence of the disorder suggesting complex bidirectional links with the clinical manifestations. We suggest that a more holistic view of ASD and other disorders is warranted to account for the multiple sites impacted by the original intra-uterine insult. From this perspective, large-spectrum active repositioned drugs that act centrally and peripherally might constitute a useful approach to treating these disorders.
Collapse
Affiliation(s)
- Eric Delpire
- Departments of Anesthesiology and Molecular Physiology & Biophysics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Correspondence:
| | - Yehezkel Ben-Ari
- NeuroChlore, Campus Scientifique de Luminy, 163 Route de Luminy, 13273 Marseilles, France
| |
Collapse
|
9
|
Nehlig A, Sperling MR. The debate on the treatment of neonatal seizures introductory remarks. Epilepsia 2022; 63:1862. [PMID: 35524449 DOI: 10.1111/epi.17275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022]
|
10
|
Sortino V, Marino S, Praticò A, Criscione R, Ruggieri M, Pisani F, Falsaperla R. Efficacy of the anti-seizure medications in acute symptomatic neonatal seizures caused by stroke. A systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022328. [PMID: 36533757 PMCID: PMC9828920 DOI: 10.23750/abm.v93i6.13440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Neonatal stroke is the second cause of acute symptomatic neonatal seizures after hypoxic-ischemic encephalopathy. The aim of this systematic review is to determine which drug among those available represents the best therapeutic choice for treatment of secondary seizures due to neonatal stroke. METHODS We performed a systematic review searching on PubMed the keywords "Neonatal", "Stroke", "Seizures" and "Treatment". Search was limited only to English language with no time limit. Last literature search was done on May 30, 2022. RESULTS We selected 5 articles involving a total of 52 full-term neonates. In 96.1% the first line treatment was phenobarbital and in 3.9% was used phenobarbital associated with midazolam from the seizure onset but in all of these cases it was necessary to introduce further medications for controlling the seizures. As second line treatment was used lidocaine (response rate of 53.3%), midazolam (response rate of 15.38%) bumetanide (response rate of 100%), and fosphenytoin (no response). As third line treatment was used lidocaine (response rate of 87.5%), Midazolam (response rate of 60%), levetiracetam and clonazepam (response rate of 100%). CONCLUSIONS Our review shows that the use of ASMs that act throughout a gabaergic mechanism are inadequate in controlling seizures secondary to neonatal stroke in full-term newborns. Very effective seems to be lidocaine and levetiracetam with an apparent safer profile in short and long term. Bumetanide shows promising results, but they need to be confirmed by phase 3 studies.
Collapse
Affiliation(s)
- Vincenzo Sortino
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silvia Marino
- Unit of Clinical Paediatrics, Azienda Ospedaliero-Universitaria Policlinico, “Rodolico-San Marco”, San Marco Hospital, Catania, Italy
| | - Andrea Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, AOU “Policlinico”, PO “G. Rodolico”, Catania, Italy
| | - Roberta Criscione
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, AOU “Policlinico”, PO “G. Rodolico”, Catania, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University of Roma, Italy
| | - Raffaele Falsaperla
- Unit of Clinical Paediatrics, Azienda Ospedaliero-Universitaria Policlinico, “Rodolico-San Marco”, San Marco Hospital, Catania, Italy, Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico “Rodolico-San Marco”, San Marco Hospital, University of Catania, Catania, Italy
| |
Collapse
|