Beyond the expected: Identifying broad research priorities of researchers and the cystic fibrosis community

The Cystic Fibrosis Foundation (CFF) supports research programs aimed at improving care and building a successful drug development pipeline. To ensure its research agenda meets the needs of the community it serves, the CFF sought community input into clinical research prioritization for topics not well-known as already being addressed by CFF-funded research. In 2018, clinical researchers, adults with CF, and family members were surveyed about a broad range of research topics that are perceived to receive less attention. We compared responses from researchers (n = 19) and community members (n = 135) and found groups aligned on their top three research priorities: 1) respiratory microorganism detection and treatment, 2) mental health, and 3) reducing treatment burden. We also explored whether or not those priorities align with the CFF research portfolio. Cognizance of researcher and community priorities can help inform clinical research endeavors to improve the health and well-being of people affected by CF.

Cognitive profile in Duchenne muscular dystrophy boys without intellectual disability: The role of executive functions

The aim of our prospective observational study was to assess profiles of cognitive function and a possible impairment of executive functions in a cohort of boys with Duchenne muscular dystrophy without intellectual and behavior disability. Forty Duchenne boys (range of age: 6 years to 11 years and 6 months) were assessed by Wechsler Intelligence scale and battery of tests including tasks assessing working memory and executive functions (inhibition and switching, problem solving and planning). In our cohort some aspects of cognitive function were often impaired. These included multitasking, problem solving, inhibition and working memory necessary to plan and direct goal oriented behavior. Our results support the suggestion that aspects of cognitive function could be impaired even in boys without intellectual disability and support the hypothesis that executive functions may play an important role in specific aspects of cognitive impairment in Duchenne muscular dystrophy.

Widespread Focal Cortical Alterations in Autism Spectrum Disorder with Intellectual Disability Detected by Threshold-Free Cluster Enhancement

BACKGROUND AND PURPOSE

In the past decades, a large body of work aimed at investigating brain structural anomalies accrued in autism spectrum disorder. Autism spectrum disorder is associated with intellectual disability in up to 50% of cases. However, only a few neuroimaging studies were conducted in autism spectrum disorder with intellectual disability, and none of them benefited from a nonsyndromic intellectual disability control group.

MATERIALS AND METHODS

We performed a voxelwise investigation of the structural alterations in 25 children with autism spectrum disorder with intellectual disability by comparing them with 25 typically developing children and 25 nonsyndromic children with an intellectual disability. Besides a classic voxel-based morphometry statistical approach, the threshold-free cluster enhancement statistical approach was adopted.

RESULTS

Classic voxel-based morphometry results did not survive family-wise error correction. The threshold-free cluster enhancement-based analysis corrected for family-wise error highlighted the following: 1) widespread focal cortical anomalies and corpus callosum alteration detected in autism spectrum disorder with intellectual disability; 2) basal ganglia and basal forebrain alteration detected both in autism spectrum disorder with intellectual disability and in nonsyndromic intellectual disability; and 3) differences in the frontocingulate-parietal cortex between autism spectrum disorder with intellectual disability and nonsyndromic intellectual disability.

CONCLUSIONS

The present study suggests that the frontocingulate-parietal cortex may be the eligible key region for further investigations aiming at detecting imaging biomarkers in autism spectrum disorder with intellectual disability. The detection of structural alterations in neurodevelopmental disorders may be dramatically improved by using a threshold-free cluster enhancement statistical approach.

Cognitive and Behavioural Effects of Migraine in Childhood and Adolescence

Since cognitive and behavioural characteristics of paediatric migraineurs have yet to be adequately defined, in this study we assessed the effect of migraine on the interictal functioning of children and adolescents by comparing the performance of two patient groups, 17 migraineurs with aura (MA) and 31 without aura (MoA) and by correlating the duration of the disorder, the frequency of attacks and interictal period with neuropsychological and behavioural findings. Both patient groups had cognitive performance within normal range except for a significant delay in the reaction time (RT) task. Both MA and MoA revealed a behavioural phenotype characterized by internalizing problems on Child Behaviour Check List (CBCL) scales. Slower RT to simple visual stimuli may be an early sign of a subclinical neuropsychological dysfunction, significantly correlated with the frequency of headache attacks and interictal period. The lack of a control group and other methodological limitations, such as patient selection bias and unadjusted P-value for multiple testing, make it difficult to give this finding a clearcut meaning. Further studies are needed on larger samples compared with a control group.

Conventional fascial technique versus mesh repair for advanced pelvic organ prolapse: Analysis of recurrences in treated and untreated compartments

117 women with severe pelvic organ prolapse (POP; stage > 2) were enrolled to elucidate a 24-month outcome of POP surgery, using conventional or mesh repair with 3 techniques. 59 patients underwent conventional repair and 58 underwent mesh repair. Two types of mesh were used: a trocar-guided transobturator polypropylene (Avaulta, Bard Inc.) and a porcine dermis mesh (Pelvisoft, Bard Inc.). Women with recurrences, who underwent previous unsuccessful conventional repair, were randomised. Primary outcome was the evaluation of anatomic failures (prolapse stage > 1) in treated and untreated compartments. Anatomic failure was observed in 11 of 58 patients (19%; CI 8.9-29) in the mesh group and in 16 of 59 patients (27.1%; p value = 0.3) in the conventional group. 9 of 11 failures in the mesh group (15.5%; CI 6.2-24.8) were observed in the untreated compartment (de novo recurrences), 14.3% in Pelvisoft and 16.7% in Avaulta arm, while only 1 recurrence in the untreated compartment (1.7%) was observed in the conventional group (odds ratio 10.6, p = 0.03).

Basal forebrain involvement in low-functioning autistic children: a voxel-based morphometry study

BACKGROUND AND PURPOSE

Imaging studies have revealed brain abnormalities in the regions involved in functions impaired in ASD (social relations, verbal and nonverbal communication, and adaptive behavior). We performed a VBM whole-brain analysis to assess the areas involved in autistic children with DD.

MATERIALS AND METHODS

Twenty-one developmentally delayed children with ASD (aged 3-10 years) were compared with 21 controls matched for age, sex, and sociocultural background. All ASD cases had been diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, with the Autism Diagnostic Observation Schedule-Generic, and the Autism Diagnostic Interview-Revised. The VBM data, covaried with intelligence quotient, age, and brain volume, were analyzed.

RESULTS

ASD patients showed a pattern of regional GM reduction symmetrically affecting the basal forebrain, accumbens nucleus, cerebellar hemispheres, and perisylvian regions, including insula and putamen. Asymmetric involvement of GM was observed in other brain regions functionally connected to the basal forebrain, ie, an area located close to the medial and ventral surface of the frontal lobe. No regional WM differences were observed between the 2 groups. No significant differences between patients and controls were found regarding total brain volume, GM, and WM.

CONCLUSIONS

In children with ASD and DD, the novel finding of our VBM study was the demonstration of reduced GM volume in the basal forebrain and the areas connected with it. This system is involved in social behavior, communication, and cognitive skills. Whether the involvement of the basal forebrain is characteristic of ASD or is related to the DD present in our patients needs further investigation.

Expanding CEP290 mutational spectrum in ciliopathies

Ciliopathies are an expanding group of rare conditions characterized by multiorgan involvement, that are caused by mutations in genes encoding for proteins of the primary cilium or its apparatus. Among these genes, CEP290 bears an intriguing allelic spectrum, being commonly mutated in Joubert syndrome and related disorders (JSRD), Meckel syndrome (MKS), Senior-Loken syndrome and isolated Leber congenital amaurosis (LCA). Although these conditions are recessively inherited, in a subset of patients only one CEP290 mutation could be detected. To assess whether genomic rearrangements involving the CEP290 gene could represent a possible mutational mechanism in these cases, exon dosage analysis on genomic DNA was performed in two groups of CEP290 heterozygous patients, including five JSRD/MKS cases and four LCA, respectively. In one JSRD patient, we identified a large heterozygous deletion encompassing CEP290 C-terminus that resulted in marked reduction of mRNA expression. No copy number alterations were identified in the remaining probands. The present work expands the CEP290 genotypic spectrum to include multiexon deletions. Although this mechanism does not appear to be frequent, screening for genomic rearrangements should be considered in patients in whom a single CEP290 mutated allele was identified.

Unilateral frontal lobe epilepsy affects executive functions in children

Very few studies to date have investigated the neuropsychological changes detectable in children suffering from frontal lobe epilepsy (FLE). The aim of the present study was to assess the effects of FLE on cognitive and executive functions in childhood. The sample includes 17 children with a frontal epileptogenic focus (10 right and 7 left), with no evidence of anatomical brain damage. These subjects were assessed by means of a battery of tests to investigate executive functioning. The results emphasised the presence of selective impairments of frontal lobe functions without evidence of deficits in global intellectual functioning. No side-specific deficits were detected, while an earlier onset of epilepsy and the duration of the disorder, but not the seizures frequency, were found to correspond with more severe deficits in some specific frontal lobe functions.

Postural instability of extremely obese individuals improves after a body weight reduction program entailing specific balance training

The purposes of this study were to compare postural stability between obese and lean subjects and to investigate the effect of a 3-week body weight reduction (BWR) program entailing specific balance training on postural stability of extremely obese patients. Time of balance maintenance and mean error on the medial-lateral direction at the trunk and lower limb level were assessed during a single limb stance on a movable platform in 19 non-obese and in 20 extremely obese individuals (age range: 20-40 yr). Time of balance maintenance was shorter (obese: 21.1+/-7.7 vs lean: 27.3+/-3.1 sec) and medial-lateral sway of the trunk was larger in obese (5.4+/-3.2 degrees) than in lean (3.2+/-1.1 degrees) subjects (p<0.05). Two subgroups of obese subjects were also tested after a BWR program (energy-restricted diet, moderate physical exercise, nutritional education and psychological counselling) combined with or without 6 sessions of specific balance training on a movable platform. BWR plus specific balance training enhanced time of balance maintenance (pre: 23.8+/-7.2 vs post: 30.0+/-0.0 sec) and reduced the trunk sway (5.2+/-2.8 degrees vs 2.6+/-0.9 degrees ) more than BWR alone (p<0.05). The present findings indicate that extremely obese individuals have inadequate postural stability (compared to their lean counterparts) that could however be improved by few sessions of specific balance training incorporated into a multidisciplinary BWR program. It was concluded that balance improvement is an important goal of rehabilitation, that would probably reduce the propensity of overweight individuals to fall while performing everyday activities.

Influenza circulating strains in Argentina exhibit differential induction of cytotoxicity and caspase-3 in vitro

BACKGROUND

Human influenza infections are a significant cause of morbidity worldwide. Though damage to the respiratory epithelium and has been related to apoptosis, which occurs subsequent to influenza virus infection, little information is available regarding cell cytotoxicity of human strains.

OBJECTIVE

To study cytotoxicity performed in vitro by various circulating strains in Argentina. The study sample consisted of three vaccine strains (H1N1, H3N2, and B) administered during 1999-2000 in South America and three strains isolated from clinical samples, one, NAC (H1N1) obtained from an adult inpatient with human pneumonia; and the other two (T) and (T2) (H3N2) with influenza syndrome. Viral antigen was detected by an immunofluorescence test, conducted prior to viral isolation in MDCK cells. Strains were subtyped by the hemmaglutination inhibition test. Cytotoxic properties were determined by lactate dehydrogenase reaction (LDH), crystal violet staining and Hoechst staining. Caspase-3 activity, morphological changes of apoptosis, and viral yields were measured in MDCK infected cells.

RESULTS AND CONCLUSIONS

Cells infected by each of the strains exhibited apoptosis morphology by Hoechst staining and caspase-3 activity was high for both H1N1 strains. Further, high levels of LDH activity were detected for NAC and H3N2 strains tested, indicating the possible role of different viral proteins or functions on cell cytotoxicity. The NAC strain, isolated from human pneumonia and antigenically related to A/New Caledonia /20/99 (H1N1), was the highest cytotoxic strain and an excellent inducer of caspase-3 activity. In turn, no parameter was related to different viral yields. We conclude that human strains studied in this paper may be useful tools in the characterization of molecular determinants involved in viral cytopathogenicity.

Intrathecal methotrexate affects cognitive function in children with medulloblastoma

BACKGROUND

Cognitive impairment occurs after malignant brain tumor treatment in children, following brain radiotherapy and systemic and intrathecal chemotherapy.

OBJECTIVES

1) To compare two groups of children who underwent surgery for cerebellar medulloblastoma with their cousins and siblings, assessing intelligence, executive function, attention, visual perception, and short-term memory. Both groups were treated with the same combined radiotherapy-chemotherapy, but differed in that only one group received intrathecal methotrexate (MTX+). 2) To relate these measures to MRI findings (leukomalacia).

RESULTS

The two groups performed worse than their control subjects in all tests. The MTX+ group younger than 10 years performed significantly worse in all tests, particularly executive ones. The group older than 10 years performed significantly worse only in short-term memory. Younger patients without MTX performed significantly worse than controls only in some neuropsychological measures; there were no differences between older patients and control subjects. Only in the MTX+ group was there a direct correlation between extent of leukomalacia and performance in some tests.

CONCLUSIONS

The administration of intrathecal methotrexate to children with medulloblastoma worsens the cognitive deficits induced by chemotherapy and radiotherapy. The use of intrathecal methotrexate in the treatment of medulloblastoma and other malignancies should be reassessed.

Developmental patterns of verbal and visuospatial spans

This study presents developmental data for verbal and spatial memory tasks: Corsi's block-tapping test and Luria's verbal learning test. Norms have been collected from 275 primary and early secondary school children aged from 5 years, 4 months to 13 years, 6 months. Our results confirm a slow and constant improvement in performances over time, and the advantage of about 1.5 items of the verbal span over the spatial span supports the existence of developmental differences between separate memory systems. No significant sex difference was found even if a slight trend in verbal span favouring female subjects is present.

Papillitis as an onset sign of Leber's hereditary optic neuropathy: a case report

Leber's hereditary optic neuropathy is a maternally transmitted disease resulting from a point mutation in mitochondrial (mt) DNA. In this report we describe a case of Leber's disease with typical clinical findings but atypical ophthalmoscopic presentation. A 14-year-old boy developed severe loss of vision acuity in the left eye, with only partial recovery, followed 4 months later by the same symptoms in the right eye. Fundoscopic examination showed hyperemic papilla on the right eye and optic disc pallor on the left eye. Polymerase chain reaction analysis of lymphocytic mt-DNA revealed a point mutation at 11778. Leber's disease should be considered in young patients (not always male) with sudden visual loss and simple papillary involvement at fundoscopic examination but without the typical telangiectatic microangiopathy.

The neurodevelopmental price of survival in children with malignant brain tumours

Increasing survival rates in malignant brain tumors treatment have directed attention to the side effects of long-term disease control. Nevertheless, although the treatment protocols are continuously remodelled, the quality of life of children surviving for a long time is still poor. The most severe sequelae are neurocognitive disorders, which are associated with neurobehavioural alterations. The last are partly derived directly from the lesion localisation and treatments, but are often reinforced by academic and social failure. The deleterious effect of radiotherapy (CRT) is very well documented and confirmed in all the studies. The radiation dose delivered according to the age has reduced, but not fully eliminated, the negative influence on mental functioning. Also the CRT hyperfractionation has reduced, but not cancelled, this cognitive negative impact. Intrathecal methotrexate per se is responsible for a severe cognitive impairment, which can be even more severe in association to CRT. Some surgical approaches have been responsible for postoperative behavioural disturbances. Serial neuropsychological and behavioural evaluations, which should also include the survivors' own perception of their quality of life, are badly needed. The results of these evaluations should be covariate with several factors (age, type of surgery, lesion site, hydrocephalus, complementary therapies) in an attempt to define interdisciplinary treatment protocols to maximise survival while minimising cognitive/behavioural deficits.

A case of 3-methylglutaconic aciduria misdiagnosed as cerebral palsy

3-Methylglutaconic aciduria is a rare hereditary metabolic disorder characterized by increased urinary excretion of 3-methylglutaconic and 3-methylglutaric acids. Four clinical forms are recognized. This study presents the case of a 5-year-old male with type IV 3-methylglutaconic aciduria, initially diagnosed as "static encephalopathy." The slow evolution and other clinical characteristics, together with cerebral magnetic resonance imaging (MRI) findings, eventually directed the diagnosis to organic aciduria that was confirmed by urine test. This study proposes that the clinical criteria for childhood cerebral palsy should be rigorously respected; neuroimaging studies, particularly MRI, should be conducted to confirm the diagnosis, especially in atypical cases.

Robotics in child neurosurgery

We felt there was a need for a new device with "minimal invasive" tracking hardware, to be used in image-guided neurosurgery, and the system we designed to fill this need is now presented. It combines precision of movement, stability and self-positioning capabilities together with optically tracked registration and procedural control within the structure of a surgical microscope. The results are reduced setup time and minimal "distraction" from the procedure itself, factors of special relevance in child neurosurgery. The system is composed of a six-axis industrial robot suitable for use in the operating room, carrying a surgical microscope. Three progressive scan-synchronized infrared cameras mounted around the lenses of the scope are used to register the patient's position and track surgical instruments with reference to the registered space. Orientation of the microscope during surgery is obtained with a six-axis joystick used as a microscope handle. The system has been clinically used in 14 cases, and it has proven itself to be reliable, providing the expected performance advantages. The implementation of a tracked ultrasound or endoscope intraoperative imaging source is also described.

The cerebellum contributes to higher functions during development: evidence from a series of children surgically treated for posterior fossa tumours

We present data on the intellectual, language and executive functions of 26 children who had undergone surgery for the removal of cerebellar hemisphere or vermal tumours. The children with right cerebellar tumours presented with disturbances of auditory sequential memory and language processing, whereas those with left cerebellar tumours showed deficits on tests of spatial and visual sequential memory. The vermal lesions led to two profiles: (i) post-surgical mutism, which evolved into speech disorders or language disturbances similar to agrammatism; and (ii) behavioural disturbances ranging from irritability to behaviours reminiscent of autism. These data are consistent with the recently acknowledged role of the cerebellum as a modulator of mental and social functions, and suggest that this role is operative early in childhood.

Neuropsychological testing may predict early progression of asymptomatic adrenoleukodystrophy

OBJECTIVES

To investigate the correlation between neuropsychological and MRI findings in children with the childhood cerebral (CCALD) and asymptomatic forms of X-linked adrenoleukodystrophy (ALD) and to identify early cognitive markers that may predict disease progression in asymptomatic children with ALD.

BACKGROUND

The few published neuropsychological studies on CCALD suggest a correlation between the pattern of cognitive deficit and lesion site; however, neuropsychological performance in asymptomatic children with ALD has not been investigated.

METHODS

The authors assessed cognitive function and cerebral MRI findings in seven CCALD and eight asymptomatic ALD children.

RESULTS

The CCALD children's cognitive skills were severely compromised, especially Wechsler and executive functions. Visual perception, short-term memory, and language were generally preserved, except that naming was severely impaired. All had extensive posterior white matter deterioration. The asymptomatic children had relatively intact neuropsychological performance, but their verbal fluency was compromised and naming severely impaired. All except one had mild white matter alterations. For all the children, the majority of neuropsychological test performance correlated significantly with extent of white matter lesions.

CONCLUSIONS

The pattern of cognitive deterioration in children with CCALD and the significant correlation of neuropsychological test performance with extent of white matter lesions indicate a white matter dementia similar to that observed in adults with demyelinating diseases. The deficits found in asymptomatic children, despite their normal intelligence, suggest that careful neuropsychological investigation can identify early signs of malfunction. These may be markers of disease progression useful for selecting children for bone marrow transplant, although this will require confirmation by prospective longitudinal studies.

Developmental aspects of verbal fluency and confrontation naming in children

Developmental changes in children's verbal fluency and confrontation naming were explored in this study. One hundred and sixty children (ages 5 years and 11 months to 11 years and 4 months) completed two verbal fluency tasks (phonemic and semantic) and the Boston Naming Test (BNT). Normative data were compiled for the BNT and the phonemic and semantic fluency tasks. With the exception of the phonemic fluency task, all tests showed a linear increase from year-groups I to V, with a significant increase between year-groups I and II. Principal Component Factor Analysis was conducted to determine whether the tests evaluated similar or different functions. Two factors emerged: the first involving all of the measurements and the second explaining exclusively the phonemic fluency. These results make it possible to conclude that children also seem to have different subsystems responsible for the analysis and processing of different aspects of language.

Management of medulloblastoma and ependymoma in infants: a single-institution long-term retrospective report

To reduce the sequelae from CNS irradiation (RT), 16 children younger than 3 years with medulloblastoma-PNET (13 cases) and ependymoma (3 cases) were treated between 1987-1993 according to different postsurgical chemotherapy (CT) programs. None of these patients presented with metastases. Eleven patients were rendered disease-free by surgery, while 5 had residual tumor. Adjuvant therapy depended on patients' age, postsurgical status and parents' consent to radiotherapy (RT). Nine of the 16 infants remained alive in continuous complete remission from the first neoplasm (median follow-up 7 years). Three of them had been treated with CT alone and 6 with combined CT + RT (posterior fossa 4, whole CNS 2). Seven patients relapsed a median of 13 months after diagnosis, and all 7 of them died of their disease. Despite the omission of RT in 6 of the 16 patients and administration of only focal RT in 8 of the 16, the outcome of this series was satisfactory. Local failure (in 5/7 patients) was the major problem, despite the high dose of RT used in 2 of these 5. In 4 of 6 evaluable children school performance was satisfactory. One child in whom the entire CNS was irradiated developed glioblastoma multiforme 120 months after the first diagnosis of medulloblastoma.

The contribution of the cerebellum to mental and social functions in developmental age

Here are present the data concerning the intellectual, language and frontal performances of 24 children who had undergone surgery because of cerebellar hemispheric or vermis tumors and one girl with viral cerebellitis. The children with right cerebellar tumors presented auditory sequential memory and language processing disturbances; those with left cerebellar tumors showed deficits in spatial tests and visual sequential memory. The girl with cerebellitis showed a complex neuropsychological picture with impairment in processing language and in general sequential functions. Lesions of the vermis lead to two pictures: 1) a postsurgical mutism that could be subdivided into speech disorders (even to the extent of anarthria) and true language disturbances similar to frontal aphasia; and 2) behavioral disturbances ranging from irritability to a truly autistic response. These data seem to support the recently attributed role of the cerebellum as a modulator of the superior mental and social functions.

Carbamazepine withdrawal in children with previous symptomatic partial epilepsy: effects on neuropsychologic function

Neurocognitive performance was evaluated in seven children with symptomatic partial epilepsy prior to, and at least 12 months after, discontinuation of carbamazepine. The patients treated with carbamazepine monotherapy were seizure-free for at least 2 years and without electroencephalographic anomalies for at least 1 year. Results indicated that carbamazepine at therapeutic levels does not affect intellectual, memory, or attentional functions, or more complex frontal functions. Nevertheless, after therapy withdrawal scores on frontal function tests used in this study improved significantly. This suggests that these functions could have been better without carbamazepine therapy. The fact that carbamazepine decreases neuron membrane excitability and could reduce the information circuity, particularly in the frontal areas, is offered as a possible explanation. Further studies on larger samples using the same design are required to validate these results.

Genotype and phenotype in patients with dihydropyrimidine dehydrogenase deficiency

Dihydropyrimidine dehydrogenase (DPD) deficiency is an autosomal recessive disease characterised by thymine-uraciluria in homozygous deficient patients and has been associated with a variable clinical phenotype. In order to understand the genetic and phenotypic basis for DPD deficiency, we have reviewed 17 families presenting 22 patients with complete deficiency of DPD. In this group of patients, 7 different mutations have been identified, including 2 deletions [295-298delTCAT, 1897delC], 1 splice-site mutation [IVS14+1G>A)] and 4 missense mutations (85T>C, 703C>T, 2658G>A, 2983G>T). Analysis of the prevalence of the various mutations among DPD patients has shown that the G-->A point mutation in the invariant splice donor site is by far the most common (52%), whereas the other six mutations are less frequently observed. A large phenotypic variability has been observed, with convulsive disorders, motor retardation and mental retardation being the most abundant manifestations. A clear correlation between the genotype and phenotype has not been established. An altered beta-alanine, uracil and thymine homeostasis might underlie the various clinical abnormalities encountered in patients with DPD deficiency.

The cerebellar contribution to language and sequential functions: evidence from a child with cerebellitis

We report the case of a 4 years and 2 months old girl, whose development was normal before she suffered from severe viral cerebellitis. When she recovered from the acute phase, a complete loss of speech was evident, although language comprehension was not impaired. Mutism disappeared after about two weeks, giving way to the aphonic utterance of a few words. After three months, her speech was slow and monotonous, without phonetic disturbances. She could only produce very simple and incomplete sentences in both spontaneous and constrained situations and she was able to maintain discourse sequentiality only under continuous guidance. No deficit in single-word recognition or naming was detected. Her sentence reproduction was good, while verbal fluency was very poor when no cue was given, but was normal with category cues. Her intelligence was within the normal range, but activities requiring programming, particularly those involving sequencing, were very defective. The patient's impairment is attributed to the failure of the cerebellar-frontal loops to activate strategies involved in processing and programming verbal and sequential functions.

Late neuropsychological and behavioural outcome of children surgically treated for craniopharyngioma

Late outcome in 12 children treated by radical surgery for craniopharyngioma is presented. None of the patients presented underwent fractionated traditional or stereotactic radiotherapy. The results show no neurological (except visual dysfunction in 6 subjects), cognitive or short-term memory deficits. Three children were found to have a minor attention deficit. In 5 cases "frontal lobe" malfunctioning was disclosed, and in 5 there were bursts of unpredictable anger. Three children showed worsening of functioning at school: a combination of various causes is suggested to explain the worsening of academic performances. The size of the sample calls for a careful evaluation of results, with due consideration for the influence of various factors on outcome. Multicentre studies are required to increase the sample size and achieve more general conclusions.

Language deficits in a child with omolateral (left) temporo-basal and cerebellar lesions

We report the case of an 8-year-old boy with two distinct brain lesions, probably hamartomas or low grade gliomas: one in the left basal temporal region, with involvement of the fusiform gyrus, the other in the white matter of the left cerebellar hemisphere. Both lesions were diagnosed at seven, when NMR was performed because of partial complex seizure. A mild delay in the first language acquisition and a long-lasting difficulty in word retrieval were reported. On neuropsychological testing, language was impaired more in production tasks than in comprehension ones, with severe deficit in word finding. The etiological role of the two different lesions is discussed in relation to experimental evidence of the existence of a distinct language area in the basal temporal region (fusiform gyrus).

Radiosurgery for cerebral AVMs in children and adolescents: the neurobehavioral outcome

Eight patients, ranging in age from 9 to 18 years, were treated for arteriovenous malformations using gamma knife radiosurgery and were evaluated an average of 6 years after treatment to record potential effects of radiosurgery on cognitive and neuropsychological performance. Tests for general intelligence, nonverbal intelligence, memory and its components, and attention performance were administered to patients and compared with test results of age-matched siblings or first cousins. No statistically significant difference was found between the performance of patients and controls in any of the tests administered. Additionally, a specially designed questionnaire completed by the patients, their parents, and their teachers revealed that the patients' emotional and relational behavior was stable and unchanged after treatment. No correlation was found between the neurocognitive test performance and the lesion volumes irradiated, but the lesion site was found to contribute to the type of deficit recorded after treatment. The less invasive nature of the radiosurgical approach, combined with the brevity or absence of hospitalization, presumably contributed to the patients successful physical, mental, and emotional recovery.

Discontinuation of phenobarbital in children: effects on neurocognitive behavior

Neurocognitive performances were evaluated in 9 children with different types of epilepsy prior to and at least 6 months after discontinuation of phenobarbital. The patients treated with phenobarbital monotherapy were seizure free for at least 2 years, without electro-encephalographic anomalies for at least 1 year. Results indicated that phenobarbital at low therapeutic doses causes attentional and memory deficits, reversible after therapy discontinuation. Further research utilizing the same design is needed on larger samples in order to confirm our results.

Stereotactically guided transfrontal removal of intraventricular midline tumors in children. Neurosurgical and neuropsychological considerations

Five children with supratentorial intraventricular midline cerebral tumors were operated on using a stereotactically guided transfrontal approach. Assisted by a three-dimensional graphic reconstruction of cerebral anatomy, the surgeon was able to reach and remove the lesion with minimal damage to healthy parenchyma. Neurosurgical and neuropsychological evaluation of the results suggests that this surgical approach is a valid alternative to the transcallosal route. This image-based intraoperative guidance is as effective as landmark-oriented surgery, which requires section of the corpus callosum, possibly leading to neuropsychological deficits, particularly in the pediatric age group.

Homozygous hypertrophic hereditary motor and sensory neuropathies

We compared 25 autosomal dominant hereditary motor and sensory neuropathy (HMSN) type I patients with 7 subjects affected by hypertrophic HMSN with non-dominant inheritance. All the autosomal dominant HMSN I cases carried the chromosome 17p11.2 duplication, providing evidence that it is widely represented in HMSN I families. The second group included: two siblings born to unrelated, unaffected parents and suffering from hypertrophic HMSN of strikingly different severity; two sisters with HMSN I phenotype, born to first-cousin unaffected parents; two brothers with HMSN III phenotype born to unrelated parents both showing HMSN II phenotype; a child with classic HMSN III phenotype, born to unrelated, unaffected parents. The 17p11.2 duplication was not found in any of the patients of the second series or in their parents. Our data provide further evidence that: HMSN III is heterogeneous and encompasses the homozygous expressions of different neuropathic genes; it is advisable to separate autosomal recessive hypertrophic HMSN from dominant HMSN Ia, because they appear to be due to different DNA mutations.

Intelligence outcome in children with shunted hydrocephalus of different etiology

Children with shunted hydrocephalus of differing etiologies were assessed. There was a more selective loss of non-verbal than of verbal intelligence. The verbal and visuo-perceptual abilities were affected by different sets of variables. Variables related to the hydrocephalus had no effects, while associated supratentorial malformations significantly affected non-verbal functions.

Visuospatial judgment: a cross-national comparison

Two samples of American and Italian 8 to 12 year-old children were compared for their performance on the Judgment of Spatial Orientation Test. No group difference emerged and, consequently, the same normative standards for performance can be applied in both countries. In both groups males performed better than females.

Neurophysiological evaluation in detrusor instability

Different and complex neuronal systems are involved in the control of continence. Detrusor overactivity has been divided by the International Continence Society into two functional subgroups: a) detrusor instability and b) detrusor hypereflexia. Only in the latter group has neurological damage been shown, but pathophysiological mechanisms are still unknown. In order to complete a full investigation of sensory and motor pathways 12 female patients affected by idiopathic detrusor instability (mean age 60.2 years; range 49-73) and 13 age-matched healthy women were studied. All patients were submitted to a subtracted cistometrogram (CMG), anal sphincter electromyography (EMG) with a bipolar coaxial needle, sacral reflex analysis after stimulation of the dorsal nerve of the clitoris, tibial and pudendal somatosensory evoked potentials, motor evoked potentials after magnetic cortical coil stimulation, and recording from anal sphincter and abductor brevis hallucis muscles. All patients had normal neurophysiological tests, and no significant differences between patients and controls could be seen. Our data confirms the absence of both clinical and subclinical damage of central sensory or motor pathways in detrusor instability; an alteration of suprasegmental mechanisms cannot be excluded.

Hemispheric specialization in children with unilateral epileptic focus, with and without computed tomography-demonstrated lesion

We evaluated 24 testable children with unilateral epileptic foci, with and without radiologically demonstrable lesions, to determine if the normal pattern of cerebral dominance is changed by the presence of an epileptic focus. Verbal and figural stimuli were presented tachistoscopically to the right and left visual hemifields to investigate the specific abilities of the two hemispheres. Three blocks of stimuli consisting of two-letter patterns, three-letter patterns, and meaningful two-syllable words were used as verbal stimuli to assess the abilities of the left hemisphere. A test consisting of localizing a dot on a 3 x 3 matrix was used to assess the abilities of the right hemisphere. Six normal children were chosen as controls. In all groups, specialization of the epileptic hemisphere was lost. The presence or absence of a radiologically demonstrable lesion did not influence this pattern.

Combined treatment modality for medulloblastoma in childhood: effects on neuropsychological functioning

8 long-surviving children, treated for medulloblastoma with combination radiotherapy and chemotherapy after surgery were examined in order to assess general intelligence, immediate attention and prolonged attention. Their siblings or first cousins were selected as controls. The children with medulloblastoma performed significantly worse than their peers, both in intelligence tests and attention tests. A trend towards a positive correlation between age at the start of treatment and IQs was confirmed in our study, while there was no evidence of a correlation between IQs and time elapsed from therapy. The role of chemotherapy, radiotherapy and their combination effect in producing neuropsychological sequelae is discussed.

Deep seated cerebral lesion removal, guided by volumetric rendering of morphological data, stereotactically acquired clinical results and technical considerations

The theoretical advantages of microsurgery guided by volumetric reconstruction of anatomy in stereotactic space, compared to traditional technique are discussed. Preliminary clinical results in 30 cases and technical considerations, concerning future developments, are presented.

Impairment of neuropsychological functions in children with medulloblastomas and astrocytomas in the posterior fossa

Neuropsychological impairment after removal of posterior fossa tumors is a recurrent issue in child neuropsychology and neurosurgery. The aim of this study was to assess verbal and performance intelligence, as well as immediate and sustained attention, in children with medulloblastoma or astrocytoma operated on for total removal of the lesion. Surgical treatment of medulloblastoma was always followed by chemoradiotherapy. Siblings of both tumor groups (without a history of neurological disease, even suspected) were examined as controls. The results were as follows: the cognitive performances were significantly poorer than the controls in both groups; the children with medulloblastoma scored below normal. Attention deficits were present in both groups as well when the usual clinical tests were used. When assessed by means of computerized methodology, the same function was normal. Considering that both groups of children underwent the same surgical treatment and all had hydrocephalus, the severe intellectual impairment reported only in patients with medulloblastoma can be ascribed to chemoradiotherapy. In contrast, the attention deficits present in both groups could be ascribed to the proximity of lesions to the ascending activating system. Malfunctioning of the activating system seems to be bypassed by the computerized administration of stimuli, which supplies motivation and kindles attention.

Development of hemisphere specialization for spatial skills in children from six to twelve years of age

208 children, male and female, aged 6 to 12 years, grouped in 6-month steps, were tested for three spatial skills: two basic abilities, recognition of two lines of differing slope and of one line of differing slope in a frame and with no frame, and one more complex skill, route-finding by means of maps. The results support the hypotheses of neuropsychological development according to which the hemisphere strategies used in the course of cognitive development for the handling of spatial tasks differ by sex and may change before and after the age of ten.

Late effects of unilateral brain lesions sustained before and after age one

Forty-eight children with unilateral cerebral lesions, incurred before or after the first year of life, were given the Wechsler Intelligence Scale for Children, with an average delays of 4 and 8 1/2 yr for the late and early injuries, respectively. Thirty-one of their siblings were chosen as controls. Results are as follows: early and late right-hemisphere lesions significantly lower only Performance IQ. Early left lesions impair equally Verbal and Performance IQ, while late left-hemisphere lesions do not significantly affect Verbal or Performance IQ relative to controls.