70 mJ nonlinear compression and scaling route for an Yb amplifier using large-core hollow fibers

In this Letter, we investigate the energy-scaling rules of hollow-core fiber (HCF)-based nonlinear pulse propagation and compression merged with high-energy Yb-laser technology, in a regime where the effects such as plasma disturbance, optical damages, and setup size become important limiting parameters. As a demonstration, 70 mJ 230 fs pulses from a high-energy Yb laser amplifier were compressed down to 40 mJ 25 fs by using a 2.8-m-long stretched HCF with a core diameter of 1 mm, resulting in a record peak power of 1.3 TW. This work presents a critical advance of a high-energy pulse (hundreds of mJ level) nonlinear interactions platform based on high energy sub-ps Yb technology with considerable applications, including driving intense THz, X-ray pulses, Wakefield acceleration, parametric wave mixing and ultraviolet generation, and tunable long-wavelength generation via enhanced Raman scattering.

Is Post-Reprocessing Microbiological Surveillance of Duodenoscopes Effective in Reducing the Potential Risk in Transmitting Pathogens?

Background: The use of a contaminated endoscope may lead to infections due to the transmission of potential pathogens from patient to patient. Methods: Post-reprocessing microbiological surveillance of four duodenoscopes was carried out over a three-year period in the Digestive Endoscopy Unit of an Italian hospital. Sampling of duodenoscopes was performed after the devices have been reprocessed. The initial phase of surveillance involved the contemporary evaluation of the four duodenoscopes; afterwards, microbiological surveillance proceeded at monthly intervals. Results: The initial phase of surveillance revealed that three duodenoscopes presented a high level of contamination with “high-concern” micro-organisms, some of which were multi-drug-resistant. The highest values of contamination regarded the species P. aeruginosa (2500 CFU/duodenoscope), K. pneumoniae (2580 CFU/duodenoscope), and A. baumannii (2600 CFU/duodenoscope). Since the cultures were repeatedly positive on three successive occasions, the contaminated devices were sent to the manufacturer for evaluation. Audits were carried out with the personnel responsible for reprocessing, which was aimed to optimize the procedures used, and subsequently, only one case of non-conformity was found. Conclusions: Our study highlighted both the potential risk of transmitting pathogens through the use of duodenoscopes and the importance of implementing a well-structured system of microbiological surveillance and training programs, in order to reduce the risk of spreading retrograde cholangiopancreatography (ERCP)-associated infections.

High accumulation of metformin in colonic tissue of subjects with diabetes or metabolic syndrome

1557

Background: Epidemiological studies consistently observed an association between metformin use in diabetic patients and decreased colon cancer incidence and mortality at clinical doses (1500-2250 mg day), corresponding to plasma levels of 0.003-0.045 mM. Preclinical models report much higher doses of metformin, ranging between 1 and 40 mM for in vitro and 0.006-0.145 mM for in vivo studies. A recent trial using a low dose of metformin (250 mg/day, Higurashi T et al. Lancet 2016;17:475) showed a 40% reduction of colorectal adenoma recurrence. We performed a pilot study to measure metformin in plasma and colonic tissue of subjects with diabetes or metabolic syndrome and to explore their correlation with different tissue biomarkers, including Ki-67, pS6k, a mTOR effector protein, and EGFR expression. Methods: We used LC-MS/MS to quantify metformin in plasma and colonic tissues from 13 volunteers with diabetes or metabolic syndrome undergoing screening colonoscopy. All patients had received metformin at 1000-1850 mg/day for a median of 6.5 yrs (range 2-15), except for one who served as untreated control. Tissue quantifications were performed on specimens derived from right and left colon biopsies with or without washing to exclude a potential contamination due to lumen accumulation by the drug. Biomarker assessment was performed by standard IHC assay. Results: The mean plasma metformin was 0.025 mM/L (range 5x10-5-0.017), whereas the colonic tissue was ~100 fold higher in right [0.39 mM/Kg (range 0.034-1.75)] and left colon [0.46 mM/Kg (range 5x10-3-1.86)]. There was no significant difference between washed and unwashed biopsies. No significant correlations were detected between metformin levels in plasma/tissue and tissue biomarkers. Conclusions: Metformin can attain ~100 fold higher colonic tissue levels than in plasma. These levels are in the range of a direct antitumor effect observed in in vivo preclinical models. A two-by-two clinical trial of metformin and aspirin in colon cancer patients is underway by our group to further elucidate independent and synergistic antitumor effects.

A randomized, placebo-controlled, preoperative trial of allopurinol in subjects with colorectal adenoma

Inflammation and oxidative stress play a crucial role in the development of colorectal cancer (CRC) and interference with these mechanisms represents a strategy in CRC chemoprevention. Allopurinol, a safe molecular scavenger largely used as antigout agent, has been shown to increase survival of patients with advanced CRC and to reduce CRC incidence in long-term gout users in epidemiologic studies. We conducted a randomized, double-blind, placebo-controlled preoperative trial in subjects with colorectal adenomatous polyps to assess the activity of allopurinol on biomarkers of colorectal carcinogenesis. After complete colonoscopy and biopsy of the index polyp, 73 subjects with colorectal adenomas were assigned to either placebo or one of two doses of allopurinol (100 mg or 300 mg) and treated for four weeks before polyp removal. Change of Ki-67 labeling index in adenomatous tissue was the primary endpoint. Secondary endpoints were the immunohistochemical (IHC) expression of NF-κB, β-catenin, topoisomerase-II-α, and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) in adenomatous polyps and normal adjacent colonic tissue. Compared with placebo, Ki-67 levels were not significantly modulated by allopurinol, whereas β-catenin and NF-κB expression levels decreased significantly in adenomatous tissue, with a mean change from baseline of -10.6%, 95% confidence interval (CI), -20.5 to -0.7, and -8.1%, 95% CI, -22.7 to 6.5, respectively. NF-κB also decreased significantly in normal adjacent tissue (-16.4%; 95% CI, -29.0 to -3.8). No dose-response relationship was noted, except for NF-κB expression in normal tissue. Allopurinol can inhibit biomarkers of oxidative activation in colon adenomatous polyps and normal adjacent tissue. Further studies should define its potential chemopreventive activity.

Abstract A57: Randomized double-blind trial of a rational combination of anthocyanins and curcumin for colon cancer prevention in subjects with colorectal adenomas: MIRACOL study

Rationale: Colorectal cancer (CRC) is one of the most frequent malignant neoplasms in both sexes within developed countries. Colorectal carcinogenesis is a multistage process that occurs over a period of 10–20 years. Colorectal adenomas (CA) are well recognized CRC risk markers. Evidence from epidemiological studies and clinical trials, suggests that removal of CA decreases the incidence of CRC, supporting the hypothesis that regression or elimination of CA through chemopreventive strategies would also reduce CRC's incidence.

Inflammation and oxidative stress appear to play a crucial role in the development of CRC; NF-kB activation has been associated with multiple pathways of oncogenesis, including apoptosis, cell cycle control, differentiation, angiogenesis and cell migration; interference with these mechanisms may represent a strategy in CRC chemoprevention.

Anthocyanins and curcumin represent, so far, the two most reliable candidates mainly due to their integrated capacity of modulating key steps of inflammatory processes, cell proliferation and tumor progression. Anthocyanins are a group of natural occurring pigments responsible for the red-blue color of many fruits and vegetables and are provided with remarkable antiproliferative, apoptogenic, antiinflammatory and antioxidant effects and with the capacity of inhibiting tumor progression in experimental models of gastrointestinal cancerogenesis. In a recent pilot study in CRC patients, anthocyanins administered for 7 days were dose-dependently effective in reducing the proliferation index Ki-67.

Curcumin is a polyphenolic compound obtained from turmeric (Curcuma longa L.) endowed with marked anti-inflammatory, antioxidant and antineoplastic effects; due to its peculiar proximal carbonyls, curcumin is also effective in interacting with the intracellular redox status contributing to modulate main steps of cellular activation and proliferation.

In the present study, we propose to test a rational combination of a natural enriched source of anthocyanins from bilberry (Vaccinium myrtillus L.), MIRTOSELECT© (standardized to contain 36 % anthocyanins) with a bioavailable form of curcumin, MERIVA©. Based on previous experience in humans, the proposed daily dosages of 1g of MIRTOSELECT© and 1g of MERIVA© would assure an effective concentration of anthocyanins and curcumin in the target tissue; and at plasmatic level.

Design: To assess the effects of MIRTOSELECT© and MERIVA© on cell proliferation in both adenomatous and unaffected colonic tissue, we designed a presurgical, double blind, placebo-controlled, randomized phase I/II trial in patients with colorectal adenomatous polyps. After a complete colonoscopy and biopsy of the index polyp, 100 subjects with histologically confirmed CA will be assigned (50 per arm) to either placebo or MIRTOSELECT© 1g/d + MERIVA© 1gr/die treatment for 4–6 weeks before polyp removal. Primary endpoint will be the nuclear transcriptional activation marker β-Catenin in adenoma tissue in subjects treated with the complex compared with placebo. The study is designed to have 85% power to detect an absolute difference of 10% between arms in β-Catenin expression levels in adenoma tissue after treatment, assuming 10% lost to follow-up.

Secondary endpoints include treatment modulation of biomarkers of oxidative activation (NF-kB), proliferation and apoptosis (Ki67, TUNEL), phlogosis (u-CRP), circulating IGFs (IGF-1, IGFBP-3), genetic expression profile and tolerability.

Citation Information: Cancer Prev Res 2011;4(10 Suppl):A57.

Abstract A69: Randomized, presurgical study of allopurinol vs. placebo in subjects with colorectal adenomas

Rationale: Colorectal adenomas are well recognized colorectal cancer (CRC) risk markers, and regression of adenomas through chemopreventive strategies may reduce the incidence of CRC. Inflammation and oxidative stress appear to play a crucial role in the development of CRC, and interference with the mechanisms inducing oxidative stress and possibly cancer progression may represent a new strategy in CRC chemoprevention. Colonic cancerous tissue contains high levels of reactive oxygen metabolites (ROM), which may play an important role in the pathogenesis of CRC, and the effects of ROM scavengers are presently being tested for CRC chemoprevention.

Allopurinol, a structural analogue of hypoxanthine inhibiting the action of xantine oxidase (XO), is a ROM scavenger largely employed as an anti-gout agent in clinical practice. Allopurinol use is highly safe, with very uncommon adverse events. Allopurinol was shown to increase survival of patients with advanced CRC, and a recent population-based case-control study showed that its use for at least 5 years was correlated with a diminished risk of developing CRC (Odds Ratio=0.33; 95% CI=0.16-0.71, Rennert G et al. AACR 3rd International Conference on Frontiers in Cancer Prevention Research 2004, Abstract #C88) after adjustment for other known risk factors.

Design: To assess the effects of allopurinol on cell proliferation in both adenomatous and unaffected colonic tissue, we designed a randomized phase I/II, double blind, placebo-controlled, multicenter trial in patients with colorectal adenomatous polyps. After a complete colonoscopy and biopsy of the index polyp, subjects with histologically confirmed adenomas were assigned to either placebo or two doses of allopurinol (100mg or 300mg) and treated for 4-6 weeks before polyp removal. Samples of normal colonic tissue were also collected on both baseline and end-of-study colonoscopy. Treatment effect on cell proliferation was assessed by measuring changes of Ki-67 labeling index (primary endpoint: Ki-67 %change) on both adenomatous and normal colonic tissue. We calculated a total of 75 subjects (25 per arm), required (α = 0.05, 1-β = 0.85, one-sided test) to show a 27% to 40% reduction in Ki-67 LI depending on standard deviation of Ki-67. Secondary endpoints included treatment modulation of biomarkers of oxidative activation (NF-Kb and β-catenin), apoptosis (topoisomerase-II-α, Cox-3, Bcl-2), inflammation (u-CRP) and of circulating IGFs (IGF-1, IGFBP-3).

Preliminary results: The first patient entered the study on May 13th 2006 and the last on May 31th, 2010, for a total study enrolment duration of about 4 years. Enrolment stopped on July 1, 2010, with a total of 73 subjects enrolled.

An interim analysis performed on November 2008 (48 patients enrolled, mean age 62 yrs, mean BMI 25kg/m2) showed a 98% treatment compliance, with only 3 G1 adverse events (1 leg cramps, 1 erythema and 1 skin rush), confirming the high safety of allopurinol. Ki-67 analysis on the first 13 subjects enrolled showed a favourable trend: median Ki-67 expression in normal tissue doubled on placebo compared with a 5% increase in both treatments arms; in adenomas, it increased by 70% on placebo compared with 6% and 12% in the 100 mg and 300 mg allopurinol arm, respectively.

Tissue and serum biomarker analyses on all subjects enrolled are underway and further results will be presented at the conference.

Citation Information: Cancer Prev Res 2010;3(12 Suppl):A69.

The treatment of functional dyspepsia with red pepper

AIM

: To decrease the intensity of dyspeptic symptoms by impairing the visceral nociceptive C-type fibres with capsaicin, contained in red pepper powder.

METHODS

: The study was performed on 30 patients with functional dyspepsia and without gastro-oesophageal reflux disease and irritable bowel syndrome. After a 2-week washout period, 15 patients received, before meals randomly and in a double-blind manner, 2.5 g/day of red pepper powder for 5 weeks, and 15 patients received placebo. A diary sheet was given to each patient to record, each day, the scores of individual and overall symptom intensity, which subsequently were averaged weekly and over the entire treatment duration.

RESULTS

: The overall symptom score and the epigastric pain, fullness and nausea scores of the red pepper group were significantly lower than those of the placebo group, starting from the third week of treatment. The decrease reached about 60% at the end of treatment in the red pepper group, whilst placebo scores decreased by less than 30%.

CONCLUSIONS

: Red pepper was more effective than placebo in decreasing the intensity of dyspeptic symptoms, probably through a desensitization of gastric nociceptive C-fibres induced by its content of capsaicin. It could represent a potential therapy for functional dyspepsia.

Combined laparoendoscopic approach for biliary lithiasis treatment

BACKGROUND/AIMS

The treatment of common bile duct stones diagnosed during videolaparoscopic cholecystectomy is still under debate. In cases of suspected common bile duct stones, a double approach with endoscopic retrograde cholangiopancreatography either prior to, or following videolaparoscopic cholecystectomy is the current routine in many centers. An intraoperative endoscopic retrograde cholangiopancreatography with endoscopic papillosphincterotomy and stone extraction has recently been proposed.

METHODOLOGY

We compared the approaches for suspected common bile duct stones in 21 cases of combined intervention endoscopic retrograde cholangiopancreatography during videolaparoscopic cholecystectomy to 17 cases of sequential intervention (endoscopic retrograde cholangiopancreatography prior to videolaparoscopic cholecystectomy). Complications and postoperative monitoring are discussed and reported on the basis of hospital stay.

RESULTS

Although the efficacy and the complications are similar, patients treated with the sequential approach stayed in the hospital longer because of the double monitoring period during both after endoscopic retrograde cholangiopancreatography and after videolaparoscopic cholecystectomy.

CONCLUSIONS

A combined approach to suspected common bile duct stones during videolaparoscopic cholecystectomy could be an effective and a financially worthwhile treatment.

Twenty-four hour ambulatory antroduodenal manometry in normal subjects (co-operative study)

Circadian antroduodenal motor activity was studied in 40 normal subjects by means of a portable recording system consisting of a computerized data logger and a probe with microtransducers. The quantitative and qualitative characteristics of contraction events during the interdigestive and digestive periods, as well as during the awake and asleep periods, were analysed. The composition and timing of meals and night recumbence were standardized. In spite of the high interindividual variability in motor parameters, significant differences in the characteristics of interdigestive and digestive periods between waking and sleep states were found. This paper confirms the existence of a circadian variation in antroduodenal motor activity and provides reference values from a large series of normal subjects that can be used for statistical comparisons with those obtained from patients recorded with the same method.

A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group

BACKGROUND

Intrasphincteric injection of botulinum toxin (Botx) has been proposed as treatment for oesophageal achalasia. However, the predictors of response and optimal dose remain unclear.

AIMS

To compare the effect of different doses of Botx and to identify predictors of response.

PATIENTS/METHODS

A total of 118 achalasic patients were randomised to receive one of three doses of Botx in a single injection: 50 U (n=40), 100 U (n=38), and 200 U (n=40). Of those who received 100 U, responsive patients were reinjected with an identical dose after 30 days. Clinical and manometric assessments were performed at baseline, 30 days after the initial injection of botulinum toxin, and at the end of follow up (mean 12 months; range 7-24 months).

RESULTS

Thirty days after the initial injection, 82% of patients were considered responders without a clear dose related effect. At the end of follow up however, relapse of symptoms was evident in 19% of patients who received two injections of 100 U compared with 47% and 43% in the 50 U and 200 U groups, respectively. Using Kaplan-Meier analysis, patients in the 100x2 U group were more likely to remain in remission at any time (p<0.04), with 68% (95% CI 59-83) still in remission at 24 months. In a multiple adjusted model, response to Botx was independently predicted by the occurrence of vigorous achalasia (odds ratio 3.3) and the 100x2 U regimen (odds ratio 3.2).

CONCLUSIONS

Two injections of 100 U of Botx 30 days apart appeared to be the most effective therapeutic schedule. The presence of vigorous achalasia was the principal determinant of the response to Botx.

Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia. The Gismad Achalasia Study Group

BACKGROUND

Intrasphincteric injection of botulinum toxin has been reported as a safe and effective alternative treatment in oesophageal achalasia, especially in high-risk and elderly patients.

AIM

: To compare two formulations of botulinum toxin in the management of achalasia.

PATIENTS AND METHODS

We randomly compared the efficacy and safety of 100 U of Botox (Allergan, Irvine, USA) and 250 U of Dysport (Ipsen, Milan, Italy), injected through a sclerotherapy needle at the level of the lower oesophageal sphincter, in 78 consecutive patients with achalasia. Symptom score, oesophageal manometry and 24 h pH-metry were recorded (before and 1 month after therapy). Symptom score was also obtained 6 months after treatment.

RESULTS

One month after treatment, the effects of the toxin on symptoms and oesophageal tests were similar for both formulations. Lower oesophageal sphincter pressure decreased from 31 +/- 12 to 18 +/- 5 mmHg after Botox, and from 35 +/- 9 to 18 +/- 10 after Dysport. At the end of the follow-up period (6 months), symptom score decreased from 5 +/- 1.2 to 1.2 +/- 0.8 after Botox and from 5.2 +/- 1.5 to 1.5 +/- 1 after Dysport. Moreover, the percentages of patients who failed to respond to treatment (10% and 17.5%) and who relapsed during follow-up (12% and 24%) did not differ significantly. No patient complained of reflux symptoms after treatment, although abnormal acid exposure was documented in two subjects.

CONCLUSIONS

Both formulations of botulinum toxin have comparable efficacy in the treatment of oesophageal achalasia, for up to 6 months of follow-up.

Isosorbide dinitrate or nifedipine: which is preferable in the medical therapy of achalasia?

Oesophageal motor activity was recorded manometrically with a low compliance system in 16 patients with achalasia and a slightly dilated oesophagus. After a basal recording period, nifedipine 20 mg was given sublingually to 9 patients and isosorbide dinitrate 5 mg to another 7 patients. Lower oesophageal sphincter pressure (LESp) and oesophageal body pressure wave amplitude were measured for 60 min after drug administration. Both drugs decreased LESp and pressure wave amplitude, but the effect of isosorbide dinitrate was faster and more intense than that of nifedipine. There was a lower inhibitory effect of nifedipine on the amplitude of pressure waves than on LESp, while isosorbide dinitrate inhibited with a similar intensity both LESp and pressure waves.

Intraluminal high dose rate brachytherapy combined with external radiotherapy in the treatment of oesophageal cancer

Twenty eight patients with previously untreated oesophageal carcinoma without distant metastases were divided into two groups: Group A consisted of 18 pts. treated with conventional external radiotherapy only. Another group of 10 pts. (Group B) received treatment with external beam irradiation with further high dose rate intraluminal brachytherapy up to a dose of 4-12 Gy delivered in 2-3 sessions of 4 Gy (one session a week). All pts. were evaluated clinically, radiologically and endoscopically every 3 months. At the end of treatment there was a marked difference in relief of dysphagia (39% in Group A vs. 90% in Group B), local control (56.7% in Group A vs. 100% in Group B) and time to progression of dysphagia (20.8 weeks in Group A vs. 67.7 weeks in Group B). No marked difference was observed in overall survival. The complication rate was low in both groups and major complications were observed in pts. treated with external radiotherapy alone (two fistulas). The association of external beam and intraluminal radiotherapy can give a better local control of the disease, improving the quality of life.

Return of esophageal peristalsis after nifedipine therapy in patients with idiopathic esophageal achalasia

This study was carried out to demonstrate the possible return of esophageal peristalsis in patients affected by esophageal achalasia chronically treated with sublingual nifedipine and to investigate which parameters are correlated with the return of peristalsis. Thirty-two patients were treated with sublingual nifedipine 10-20 mg taken 30 min before meals. A clinical and manometric evaluation was performed before and after 6 months of therapy. Before treatment, in no patient was peristaltic activity recorded. After 6 months, peristalsis was observed in six patients. In this group, no pretreatment manometric parameter was different from that of the remaining achalasic patients; only the clinical history of dysphagia was significantly shorter (p < 0.001) and the esophageal diameter significantly less (p < 0.001). In conclusion, chronic treatment with sublingual nifedipine can induce a return of esophageal peristalsis in patients with a short clinical history of disease and slightly dilated esophagus.

[Adenocarcinoma of the distal esophagus treated with external and intracavitary radiotherapy. Description of a clinical case and review of the literature]

The prognosis of esophageal adenocarcinoma is extremely poor. Despite recent improvements in diagnostic and therapeutic techniques, the 5-years survival rate remains below 10%. Management is primarily surgical or radiotherapeutical, although pre- or postoperative radiation or chemotherapy are often employed. Chemotherapy alone, however, has not demonstrated great therapeutic efficacy in the management of this neoplasm. As most patients with cancer of the lower esophagus have an advanced stage of the disease and a very poor prognosis, the main aim of treatment should be to improve the quality of life. Intracavitary radiation (high dose rate) is a well recognised method of treatment alone or in combination with external radiotherapy. Its simplicity, the convenience of short treatment time and radiation safety provided by the remote after loading system make this the ideal palliative treatment in esophageal cancer. Endoscopic techniques, like dilation and endoprosthesis placement, laser therapy or BI-CAP probe, provide good palliation for dysphagia, with a low morbidity rate. The paper describes a case of lower esophageal adenocarcinoma treated with combined external and intracavitary radiation and endoscopic palliative techniques. Good control of the disease was achieved and the patient is alive 26 months after treatment with a good quality of life.

Prospective clinical and manometric study comparing pneumatic dilatation and sublingual nifedipine in the treatment of oesophageal achalasia

A study was carried out in 30 patients affected by a mild or moderate degree of oesophageal achalasia to compare the clinical and manometric effects of sublingual nifedipine and pneumatic dilatation. Sixteen patients were dilated twice with Rider-Moeller dilators and 14 were treated with sublingual nifedipine 10-20 mg 30 minutes before meals. A manometric evaluation was performed before and six months after starting treatment. The clinical evaluation (according to Vantrappen's criteria) was performed every three months for a mean follow up of 21 months. In both groups of patients a significant (p less than 0.001) fall in lower oesophageal sphincter pressure was observed after treatment and excellent or good clinical results were observed in 75% of dilated patients and in 77% of patients treated with nifedipine. One patient could not tolerate nifedipine. No complications were observed after dilatation. It is concluded that longterm treatment with sublingual nifedipine and pneumatic dilatation are equally effective in the treatment of oesophageal achalasia of mild or moderate degree.

[Manometry and drugs]

Aim of this study was to analyze the relationships between esophageal motility and pharmacology. The use of a drug during manometry may have three goals: physiopathologic, diagnostic and therapeutic. In the first case, the manometric examination after administration of drugs, hormones and neurotransmitters allows to study esophageal receptors and innervation and to understand the alterations that are at the basis of esophageal motility disorders. Pharmacological stimulations with Bethanechol and Edrophonium is useful in the diagnosis of non cardiac chest pain, when alterations of esophageal motility are sporadic and difficult to diagnose with a standard manometric examination. Finally esophageal manometry is indispensable in clinical practice to establish therapeutic activity and mechanism of action of drugs.

Assessment of autonomic functions in insulin-dependent diabetic children and adolescents

Autonomic function has been studied in 30 insulin-dependent diabetic children and adolescents, through five cardiovascular tests. A significant difference between the diabetic and the control subjects was found in heart rate variations after deep breathing and after standing. Fifty percent of our patients showed an altered response to one or more cardiovascular tests. Although clinical manifestations of autonomic dysfunction are not frequent in young insulin-dependent patients, early signs of functional alterations are detectable in a high percentage of them.

Multifactorial etiological aspects of epilepsy

The results of a computerized analysis of 555 newly recognized idiopathic epilepsy patients (301 males and 254 females) are presented. All patients were under 30 years over the period 1980-1985. The possible prenatal and perinatal risk factors (RFs) for epilepsy were investigated. The data showed that 307 patients (55.5%) had possible RFs; 162 had one possible RF, 145 two or more. The association of two or more RFs had a high frequency in secondary generalized epilepsy (66.6%) and in partial epilepsy. A multifactorial etiology of epilepsy is suggested, hypothesizing a connection either between prenatal and perinatal RFs or between multiple perinatal RFs.

Prosopagnosia. Report of four cases

4 patients with prosopagnosia are described. They presented associated neuropsychological deficits (achromatopsia, topographical disorientation) and visual field defects. In 1 case, gross pathological examination revealed bilateral symmetrical infero-medial occipito-temporal infarcts. In 2 other cases, computer tomography (CT) demonstrated bilateral inferior temporo-occipital infarction. In 1 case CT showed only occipital infarctions in the occipital lobes. This brings to 16 the number of anatomically studied cases of prosopagnosia (8 by necropsy, 8 by CT). In contrast to clinical localization, which often indicates only a right cerebral lesion, all anatomically verified cases of prosopagnosia exhibit bilateral lesions in the posterior cerebral artery distribution.