Carney complex predisposes to breast cancer: prospective study of 50 women

OBJECTIVE

Carney complex (CNC) is a rare genetic syndrome, mostly due to germline loss-of-function pathogenic variants in PRKAR1A. Carney complex includes pigmented skin lesions, cardiac myxomas, primary pigmented nodular adrenocortical dysplasia, and various breast benign tumors.

DESIGN

The present study was designed to describe the characteristics of breast lesions in CNC patients and their association with other manifestations of CNC and PRKAR1A genotype.

METHODS

A 3-year follow-up multicenter French prospective study of CNC patients included 50 women who were analyzed for CNC manifestations and particularly breast lesions, with breast imaging, genotyping, and hormonal settings.

RESULTS

Among the 38 women with breast imaging, 14 (39%) had breast lesions, half of them bilateral. Ten women (26%) presented with benign lesions and six with breast carcinomas (16%): one had ductal carcinoma in situ at 54, and five had invasive cancer before 50 years old, whom one with contralateral breast cancer during follow-up. The occurrence of breast cancer was more frequent in women with PRKAR1A pathogenic variant odds ratio = 6.34 (1.63-17.91) than in general population of same age. The mean age at breast cancer diagnosis was 44.7 years old: 17 years younger than in the general population. Breast cancer patients had good prognosis factors. All breast carcinomas occurred in individuals with familial CNC and PRKAR1A pathogenic variants. Loss of heterozygosity at the PRKAR1A locus in the 2 invasive breast carcinomas analyzed suggested a driver role of this tumor suppressor gene.

CONCLUSIONS

As CNC could predispose to breast carcinoma, an adequate screening strategy and follow-up should be discussed in affected women.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.gov NCT00668291.

Increased Incidence of Intracranial Meningiomas in Patients With Acromegaly

BACKGROUND

An increased incidence of various neoplasms has been described in patients with acromegaly, and there is evidence to suggest that growth factors are risk factors for the development of meningiomas.

OBJECTIVE

To study if patients with acromegaly are more at risk for developing intracranial meningiomas.

METHODS

We conducted an observational study on 221 consecutive acromegalic patients recruited between January 1, 2000 and December 31, 2015, and 357 consecutive patients with a nonsomatotropic pituitary adenoma recruited between March 1, 2015 and December 31, 2016, in our institution. Patients underwent a gadolinium-enhanced 3D T1 brain magnetic resonance imaging to look for meningiomas. The proportion of meningiomas was compared between the 2 groups, and the standardized incidence ratio (SIR) was computed from the incidence rates of meningiomas observed in the population of acromegalic patients and compared to that of the general population given by the local registry of central nervous system tumors.

RESULTS

Patients with acromegaly had a significant risk for developing intracranial meningiomas as compared to patients without acromegaly (7.7% vs 2.2%, P = .005, OR = 3.45 [1.46; 8.15]). There was a significant increased incidence of intracranial meningiomas in patients with acromegaly (SIR = 126 [25; 367]) as compared to the general population.

CONCLUSION

Our study suggests strongly that patients with acromegaly are more at risk for developing intracranial meningiomas.

[Chronic pheochromocytoma-induced myocardial injuries: What should we expect from modern and classical echocardiographic tools?]

INTRODUCTION

Pheochromocytoma is a rare disease, which may manifest as severe cardiac complications. Apart from these situations, the "chronic" cardiac impact is not clearly defined. A cardiac MRI study suggests that these patients are carrying areas of fibrosis and foci of left ventricular myocarditis. Since these abnormalities are usually associated with altered left ventricular longitudinal systolic strain, we hypothesize that this strain is altered in patients with a "chronic" pheochromocytoma.

METHOD

This retrospective case-control study was performed using patients from the Bordeaux University Hospital database, included between 2008 and 2016. We compared the left ventricular global longitudinal strain (GLS), radial and circumferential systolic strain and classic echocardiographic parameters between patients with pheochromocytoma and controls matched for age, sex, body mass index and systolic blood pressure.

RESULTS

The analysis included 47 patients and 47 correctly matched controls. There were no statistically significant differences between the 2 groups in terms of GLS (-20.7±2.4% vs. -20.2±2.7%, P=0.40), radial strain, left ventricular mass or diastolic function. Left ventricular ejection fraction and circumferential strain were significantly higher in patients than in controls, with a significantly lower telediastolic diameter.

CONCLUSION

No significant changes in GLS were observed in our pheochromocytoma patients, compared with controls. Several hypotheses may explain these results. The presence of fibrosis foci and areas of left ventricular myocarditis being associated with a poor cardiological prognosis, a systematic cardiac MRI could be discussed in these patients, until further studies are performed.

Frequency and Incidence of Carney Complex Manifestations: A Prospective Multicenter Study With a Three-Year Follow-Up

INTRODUCTION

Carney Complex (CNC) is a rare multiple endocrine and nonendocrine neoplasia syndrome. Manifestations and genotype-phenotype correlations have been described by retrospective studies, but no prospective study evaluating the occurrence of the different manifestations has been available so far.

METHODS

This multicenter national prospective study included patients with CNC, primary pigmented nodular adrenal disease (PPNAD), or a pathogenic PRKAR1A mutation; after a full initial workup, participants were followed for 3 years with annual standardized evaluation.

RESULTS

The cohort included 70 patients (50 female/20 male, mean age 35.4 ± 16.7 years, 81% carrying PRKAR1A mutation). The initial investigations allowed identification of several manifestations. At the end of the 3-year follow-up, the newly diagnosed manifestations of the disease were subclinical acromegaly in 6 patients, bilateral testicular calcifications in 1 patient, and cardiac myxomas in 2 patients. Recurrences of cardiac myxomas were diagnosed in 4 patients during the 3-year follow-up study period. Asymptomatic abnormalities of the corticotroph and somatotroph axis that did not meet criteria of PPNAD and acromegaly were observed in 11.4% and 30% of the patients, respectively. Patients carrying the PRKAR1A c.709-7del6 mutation had a mild phenotype.

CONCLUSION

This study underlines the importance of a systematic follow-up of the CNC manifestations, especially a biannual screening for cardiac myxoma. By contrast, regular screening for the other manifestations after a first extensive workup could be spread out, leading to a lighter and more acceptable follow-up schedule for patients. These are important results for recommendations for long-term management of CNC patients.

Pasireotide-LAR in acromegaly patients treated with a combination therapy: a real-life study

PURPOSE

Little data are available regarding the safety and efficacy of switching to Pasireotide-LAR monotherapy in acromegaly patients with partial resistance to first-generation somatostatin agonists (1gSRL) who require combination treatment with cabergoline or pegvisomant.

METHOD

In this monocentric prospective study within a tertiary university hospital, 15 consecutive acromegalic adults partially resistant to 1gSRL treated with octreotide LAR or lanreotide SR, and cabergoline (n = 4, 3.5 mg/week) or pegvisomant (n = 11, median dose 100 mg/week), were switched to Pasireotide-LAR (8 with 40 mg/month; 7 with 60 mg/month). Immunohistochemical expression level of SSTR5 and the granulation pattern of nine somatotroph adenomas were retrospectively determined to test for a correlation with the therapeutic efficacy of Pasireotide-LAR.

RESULTS

Median IGF-1 concentration at the first evaluation (median 3 months) was similar to baseline (1.0 vs 1.1 ULN). 11/15 patients had IGF-1 levels ≤1.3 ULN before and after the switch but individual changes were variable. Hyperglycemia was frequent and greater in diabetic patients. 7/15 patients stopped Pasireotide-LAR due to lack of control of IGF-1 or intolerance. 8/15 patients received Pasireotide-LAR for a median of 29 months with IGF-1 levels ≤1.3 ULN and acceptable glucose tolerance (median HbA1c 6.1%). Two patients required initiation of oral antidiabetic treatment. The intensity of SSTR5 expression and the granulation pattern of adenomas were of limited value for the prediction of Pasireotide-LAR effectiveness.

CONCLUSION

Pasireotide-LAR may represent a suitable therapeutic alternative in a subset of acromegalic patients requiring combination therapy involving a 1gSRL.

SUN-444 Efficacy and Safety of Dopamine Agonists in Psychiatric Patients Treated with Antipsychotics and Presenting a Macroprolactinoma

Dopamine agonists (DAs), which are used as first line therapy in patients with macroprolactinomas, and antipsychotics have opposite effects on D2 dopamine receptors. In patients with severe psychiatric conditions treated with antipsychotics, the rare occurrence of a macroprolactinoma, particularly when it compresses the optic chiasm represents a therapeutic challenge. Indeed, on one hand, antipsychotics by their antagonistic effect on D2 receptors, could decrease or even abolish the effects of DAs on prolactinomas; on the other hand, DAs could make antipsychotics ineffective and lead to psychiatric exacerbation. Our retrospective study aimed at evaluating the efficacy and psychiatric safety of DAs prescribed for the treatment of large prolactin (PRL)-secreting macroadenomas in patients whose underlying psychiatric disorder necessitated treatment with antipsychotics. Endocrinological and psychiatric data on 18 patients were obtained from clinical charts collected in several Endocrinology centers in France and Belgium. Results are expressed as median value (interquartile range). Each of the 18 patient received DAs. Nine had also pituitary surgery (most often because of insufficient tumoral response) and two had radiotherapy. The median decrease of prolactin (PRL) levels, under DA, was -94.7 (30.6) % for the 8 patients treated with DAs only [from an initial median level of 1247 (13012) ng/ml to a minimal level of 42 (244) ng/ml, p=0.008], -85,5 (16,5) % for the 7 patients treated before surgery [3850 (8831) ng/ml to 141 (1510) ng/ml, p=0.03] and -18 (62,75)% for the 6 patients treated after surgery [1664 (1473) ng/ml to 1215 (3094) ng/ml, p=0.56]. The median decrease of prolactinoma largest diameter was -28 (23.5) % for patients only treated with DAs [from an initial median diameter of 27 (22.5) mm to 24 (11.75) mm after treatment; p=0.02] and it almost did not change in the patients who had surgery. Nevertheless, DA treatment allowed optic chiasm decompression in 82% of the patients. Five patients (28%) were admitted for psychiatric relapse while they were receiving DAs (but three of them had stopped their antipsychotic treatment at that time). Moreover, 89% of these patients had a history of one or more psychiatric admissions compared to 11% among those who did not have any relapse (p=0.0034). Even if DAs efficacy on PRL levels and tumoral volume in macroprolactinoma patients under antipsychotic drugs is less impressive than that observed usually, it may considered as satisfactory for half of our patients, particularly in case of optic chiasm compression. Psychiatric symptoms exacerbation was unusual in these patients, occurring mostly in those with the most severe psychiatric conditions. DAs may therefore be used as antitumoral treatment of macroprolactinoma in patients receiving antipsychotics.

Diagnostic accuracy of computed tomography to identify adenomas among adrenal incidentalomas in an endocrinological population

CONTEXT

The recent recommendations of the European Endocrine Society states that the performance of computed tomography (CT) to characterize 'true' adrenal incidentalomas (AIs) remains debatable.

OBJECTIVE

To determine relevant thresholds for usual CT parameters for the diagnosis of benign tumors using robust reference standard among a large series of 'true' AIs recruited in an endocrinological setting.

DESIGN

Retrospective study of 253 AIs in 233 consecutive patients explored in a single university hospital: 183 adenomas, 33 pheochromocytomas, 23 adrenocortical carcinomas, 5 other malignant tumors and 9 other benign tumors. Reference standard was histopathology in 118 AIs, biological diagnosis of pheochromocytoma in 2 AIs and size stability after at least 1 year of follow-up in 133 AIs.

METHODS

Sensitivity, specificity and positive and negative predictive values were estimated for various thresholds of size, unenhanced attenuation (UA), relative and absolute wash-out (RPW, APW) of contrast media. 197 scans were reviewed independently in a blinded fashion by two expert radiologists to assess inter-observer reproducibility of measurements.

RESULTS

Criteria associated with a 100% positive predictive value for the diagnosis of benign AI were: a combination of size and UA: 30 mm and 20 HU or 40 mm and 15 HU, respectively; RPW >53%; and APW >78%. Non-adenomatous AIs with rapid contrast wash-out were exclusively benign pseudocysts and pheochromocytomas, suggesting that classical thresholds of 60% and 40% for APW and RPW, respectively, can be safely used for patients with normal metanephrine values. Inter-observer reproducibility of all parameters was excellent (intra-class correlation coefficients: 0.96-0.99).

CONCLUSIONS

Our study, the largest conducted in AIs recruited in an endocrinological setting, suggests safe thresholds for quantitative CT parameters to avoid false diagnoses of benignity.

Cabergoline for Cushing's disease: a large retrospective multicenter study

OBJECTIVE

The efficacy of cabergoline in Cushing's disease (CD) is controversial. The aim of this study was to assess the efficacy and tolerability of cabergoline in a large contemporary cohort of patients with CD.

DESIGN

We conducted a retrospective multicenter study from thirteen French and Belgian university hospitals.

METHODS

Sixty-two patients with CD received cabergoline monotherapy or add-on therapy. Symptom score, biological markers of hypercortisolism and adverse effects were recorded.

RESULTS

Twenty-one (40%) of 53 patients who received cabergoline monotherapy had normal urinary free cortisol (UFC) values within 12 months (complete responders), and five of these patients developed corticotropic insufficiency. The fall in UFC was associated with significant reductions in midnight cortisol and plasma ACTH, and with clinical improvement. Compared to other patients, complete responders had similar median baseline UFC (2.0 vs 2.5xULN) and plasma prolactin concentrations but received lower doses of cabergoline (1.5 vs 3.5 mg/week, P < 0.05). During long-term treatment (>12 months), cabergoline was withdrawn in 28% of complete responders because of treatment escape or intolerance. Overall, sustained control of hypercortisolism was obtained in 23% of patients for 32.5 months (19-105). Nine patients on steroidogenesis inhibitors received cabergoline add-on therapy for 19 months (1-240). Hypercortisolism was controlled in 56% of these patients during the first year of treatment with cabergoline at 1.0 mg/week (0.5-3.5).

CONCLUSIONS

About 20-25% of CD patients are good responders to cabergoline therapy allowing long-term control of hypercortisolism at relatively low dosages and with acceptable tolerability. No single parameter, including the baseline UFC and prolactin levels, predicted the response to cabergoline.

T2-weighted MRI signal predicts hormone and tumor responses to somatostatin analogs in acromegaly

GH-secreting pituitary adenomas can be hypo-, iso- or hyper-intense on T2-weighted MRI sequences. We conducted the current multicenter study in a large population of patients with acromegaly to analyze the relationship between T2-weighted signal intensity on diagnostic MRI and hormonal and tumoral responses to somatostatin analogs (SSA) as primary monotherapy. Acromegaly patients receiving primary SSA for at least 3 months were included in the study. Hormonal, clinical and general MRI assessments were performed and assessed centrally. We included 120 patients with acromegaly. At diagnosis, 84, 17 and 19 tumors were T2-hypo-, iso- and hyper-intense, respectively. SSA treatment duration, cumulative and mean monthly doses were similar in the three groups. Patients with T2-hypo-intense adenomas had median SSA-induced decreases in GH and IGF-1 of 88% and 59% respectively, which were significantly greater than the decreases observed in the T2-iso- and hyper-intense groups (P < 0.001). Tumor shrinkage on SSA was also significantly greater in the T2-hypo-intense group (38%) compared with the T2-iso- and hyper-intense groups (8% and 3%, respectively; P < 0.0001). The response to SSA correlated with the calculated T2 intensity: the lower the T2-weighted intensity, the greater the decrease in random GH (P < 0.0001, r = 0.22), IGF-1 (P < 0.0001, r = 0.14) and adenoma volume (P < 0.0001, r = 0.33). The T2-weighted signal intensity of GH-secreting adenomas at diagnosis correlates with hormone reduction and tumor shrinkage in response to primary SSA treatment in acromegaly. This study supports its use as a generally available predictive tool at diagnosis that could help to guide subsequent treatment choices in acromegaly.

Evaluation of the Nutritional Status in Institutionalized Children and its Relationship to the Development of Epilepsy

Malnutrition as defined by the World Health Organization (WHO) in 1973 is an association of pathologic conditions caused by a lack of calories or protein intake in variable proportions. It is still one of the leading causes of infant mortality in developing countries. Risk factors for early malnutrition are absence of perinatal care and low birth weight. Epilepsy is also a very prevalent condition in childhood. A relationship between malnutrition and epilepsy has been suggested in many basic studies but it has never been proven in humans. In order to verify if malnutrition can lead to epilepsy, we reviewed anthropometric and medical files from infants in a governmental institution and tried to relate to an outcome of epilepsy. We defined malnutrition as height/weight below two pattern deviations from the NCHS tables. Two hundred and forty three children were included, 101 with malnutrition and 133 nourished. Our results indicate a predominance of malnutrition in girls (49%) and a comorbidity of malnutrition and neurological disorders. Although there were more cases of epilepsy in the malnourished group, the difference was not significant, and we could not assume that malnutrition was the cause of epilepsy in these cases because of the association of many other diseases that could also damage the central nervous system.

Evaluation of (68)Ga-DOTA-TOC PET/CT for the detection of duodenopancreatic neuroendocrine tumors in patients with MEN1

CONTEXT

Somatostatin receptor scintigraphy with (111)In-pentetreotide (SRS) is used to detect duodenopancreatic neuroendocrine tumors (dpNETs) in multiple endocrine neoplasia type 1 (MEN1). However, SRS has limited sensitivity for this purpose. Positron emission tomography/computed tomography (PET/CT) with (68)Ga-DOTA-TOC has a higher rate of sporadic dpNETs detection than SRS but there is little data for dpNETs detection in MEN1.

PURPOSE

To compare the performances of (68)Ga-DOTA-TOC PET/CT, SRS and contrast-enhanced computed tomography (CE-CT) to diagnose dpNETs in MEN1.

DESIGN AND SETTING

Single-institution prospective comparative study

PATIENTS AND METHODS

Nineteen consecutive MEN1 patients (aged 47 ± 13 years) underwent (68)Ga-DOTA-TOC PET/CT, SRS, and CE-CT within 2 months in random order. Blinded readings of images were performed separately by experienced physicians. Unblinded analysis of CE-CT, combined with additional magnetic resonance imaging, endoscopic-ultrasound, (18)F-2-fluoro-deoxy-D-glucose ((18)F-FDG) PET/CT or histopathology results served as reference standard for dpNETs diagnosis.

RESULTS

The sensitivity of (68)Ga-DOTA-TOC PET/CT, SRS, and CE-CT was 76, 20, and 60 %, respectively (p < 0.0001). All the true-positive lesions detected by SRS were also depicted on (68)Ga-DOTA-TOC PET/CT. (68)Ga-DOTA-TOC PET/CT detected lesions of smaller size than SRS (10.7 ± 7.6 and 15.2 ± 5.9 mm, respectively, p < 0.03). False negatives of (68)Ga-DOTA-TOC PET/CT included small dpNETs (<10 mm) and (18)F-FDG PET/CT positive aggressive dpNETs. No false positives were recorded. In addition, whole-body mapping with (68)Ga-DOTA-TOC PET/CT identified extra-abdominal MEN1-related tumors including one neuroendocrine thymic carcinoma identified by the three imaging procedures, one bronchial carcinoid undetected by CE-CT and three meningiomas undetected by SRS.

CONCLUSIONS

Owing to higher diagnostic performance, (68)Ga-DOTA-TOC PET/CT (or alternative (68)Ga-labeled somatostatin analogues) should replace (111)In-pentetreotide in the investigation of MEN1 patients.

Benefits and risks associated with consumption of raw, cooked, and canned tuna (Thunnus spp.) based on the bioaccessibility of selenium and methylmercury

The Se, Hg, and methylmercury (MeHg) levels in raw, cooked (boiled and grilled), and canned tuna (Thunnus spp.) were determined before and after an in vitro digestion, thereby enabling the calculation of the respective bioaccessibility percentages. A risk-benefit evaluation of raw and canned tuna on the basis of the Se and MeHg data was performed. Selenium bioaccessibility was high in tuna, though slightly lower in canned than in raw products. Mercury levels were high in raw and cooked tuna. Hg bioaccessibility percentages were low (39-48%) in the cooked tuna and even lower (<20%) in canned tuna. For the bioaccessible fraction, all molar Se:MeHg ratios were higher than one (between 10 and 74). A probabilistic assessment of MeHg risk vs Se benefit showed that while a weekly meal of canned tuna presents very low risk, raw, boiled, and grilled tuna consumption should not exceed a monthly meal, at least, for pregnant and nursing women.

Accuracy of repeated measurements of late-night salivary cortisol to screen for early-stage recurrence of Cushing's disease following pituitary surgery

OBJECTIVE

The performance of late-night salivary cortisol (LNSC) to accurately screen for postoperative recurrence of Cushing's disease (CD) at an early stage is unknown. The aim of this study was to compare the accuracy of multiple sampling strategies to suggest the optimal number of LNSC samples needed for diagnosing post-surgical recurrences of CD at an early stage.

DESIGN

Retrospective analysis in a single centre.

PATIENTS AND MEASUREMENTS

Thirty-six patients in surgical remission of CD had successive measurements of LNSC, defined as 'sequences', using a locally modified RIA assay as part of long-term follow-up (69·2 ± 10·6 months). Patients underwent an extensive biochemical evaluation within 3 months before or after a sequence of saliva sampling and were classified as being in remission or in early-stage recurrence. The accuracy of three diagnostic strategies combining two, three or four LNSC results from a sequence was estimated using areas under the ROC curves (AUC), sensitivity, specificity and predictive values.

RESULTS

Forty-four sequences of LNSC measurements were available. Fifty-two percent of sequences were performed during early-stage recurrence. The intrasequence variability of LNSC was higher during recurrence than during remission (medians of SDs: 2·1 vs 0·5 nm; P < 0·0001). AUCs from ROC curves ranged from 0·93 to 0·96 depending on the strategy. For 90% sensitivities, the best specificities (92·9% and 90·9%) were achieved by strategies taking into account three or four measurements summarized either by their mean or their maximum value.

CONCLUSIONS

Increase in LNSC concentration is an early abnormality during post-surgical recurrence of CD. However, due to a major within-patient variability of LNSC from 1 day to another, a screening strategy using three or four samples collected on successive days may be recommended to detect early-stage recurrence of CD with a high accuracy.

Seasonal variation of bacterial communities in shellfish harvesting waters: preliminary study before applying phage therapy

The recurrent emergence of infections outbreaks associated with shellfish consumption is an important health problem, which results in substantial economic losses to the seafood industry. Even after depuration, shellfish is still involved in outbreaks caused by pathogenic bacteria, which increases the demand for new efficient strategies to control the shellfish infection transmission. Phage therapy during the shellfish depuration is a promising approach, but its success depends on a detailed understanding of the dynamics of bacterial communities in the harvesting waters. This study intends to evaluate the seasonal dynamics of the overall bacterial communities, disease-causing bacterial populations and bacterial sanitary quality indicators in two authorized harvesting-zones at Ria de Aveiro. During the hot season, the total bacterial community presented high complexity and new prevalent populations of the main shellfish pathogenic bacteria emerged. These results indicate that the spring/summer season is a critical period during which phage therapy should be applied.

Normotensive incidentally discovered pheochromocytomas display specific biochemical, cellular, and molecular characteristics

CONTEXT

A number of incidentally discovered pheochromocytomas are not associated with hypertension. The characteristics of normotensive incidentally discovered pheochromocytomas (NIPs) are poorly known.

OBJECTIVE

The purpose of this work was to assess the clinical, hormonal, histological, and molecular features of NIPs.

DESIGN

This was a retrospective cohort recruited from 2001 to 2011 in 2 tertiary care medical departments.

PATIENTS AND METHODS

Clinical, biological, and radiological investigations performed in 96 consecutive patients with sporadic unilateral pheochromocytomas were examined; 47 patients had overt pheochromocytomas responsible for hypertension. Among the patients with incidental pheochromocytomas, 28 had hypertension and 21 were normotensive (NIPs). A total of 62 tumors were examined to determine the Pheochromocytoma of the Adrenal Gland Scale Score, and 29 were studied for the expression of 16 genes involved in chromaffin cell function.

RESULTS

Tumor size and metaiodobenzylguanidine (MIBG) scintigraphy results were similar for hypertensive pheochromocytomas (HPs) and NIPs. Patients with NIPs displayed reduced summed levels of urinary catecholamines and metanephrines and, more specifically, reduced levels of adrenaline and metadrenaline compared with those of patients with HPs (P < .001). Urinary metanephrines had 98% diagnostic sensitivity in patients with HPs and only 75% in patients with NIPs (P < .01). Tumor diameter positively correlated with the total amount of urinary concentrations of metanephrines in patients with HPs (P < .001) but not in patients with NIPs. NIPs displayed global decreased chromaffin gene expression (reaching significance for 5 of them) and 2 corresponding proteins (phenylethanolamine N-methyltransferase and secretogranin II) and a significant increase in the cellularity, mitotic activity, and presence of atypical mitosis (P < .05).

CONCLUSIONS

NIPs differ from pheochromocytomas responsible for hypertension and display features of altered chromaffin differentiation. These tumors may be misdiagnosed with the use of the usual biological diagnostic tools.

PIK3R1 mutations cause syndromic insulin resistance with lipoatrophy

Short stature, hyperextensibility of joints and/or inguinal hernia, ocular depression, Rieger anomaly, and teething delay (SHORT) syndrome is a developmental disorder with an unknown genetic cause and hallmarks that include insulin resistance and lack of subcutaneous fat. We ascertained two unrelated individuals with SHORT syndrome, hypothesized that the observed phenotype was most likely due to de novo mutations in the same gene, and performed whole-exome sequencing in the two probands and their unaffected parents. We then confirmed our initial observations in four other subjects with SHORT syndrome from three families, as well as 14 unrelated subjects presenting with syndromic insulin resistance and/or generalized lipoatrophy associated with dysmorphic features and growth retardation. Overall, we identified in nine affected individuals from eight families de novo or inherited PIK3R1 mutations, including a mutational hotspot (c.1945C>T [p.Arg649Trp]) present in four families. PIK3R1 encodes the p85α, p55α, and p50α regulatory subunits of class IA phosphatidylinositol 3 kinases (PI3Ks), which are known to play a key role in insulin signaling. Functional data from fibroblasts derived from individuals with PIK3R1 mutations showed severe insulin resistance for both proximal and distal PI3K-dependent signaling. Our findings extend the genetic causes of severe insulin-resistance syndromes and provide important information with respect to the function of PIK3R1 in normal development and its role in human diseases, including growth delay, Rieger anomaly and other ocular affections, insulin resistance, diabetes, paucity of fat, and ovarian cysts.

Antioxidant and antibacterial activity of essential oil and extracts of bay laurel Laurus nobilis Linnaeus (Lauraceae) from Portugal

Laurus nobilis L. is an aromatic plant frequently used as a spice in Mediterranean cookery and as a traditional medicine for the treatment of several infectious diseases. The aim of this study was to characterise the antibacterial and antioxidant activities of bay laurel essential oil (EO), ethanolic extract (EE) and hot/cold aqueous extract (AE). The major components detected in bay laurel EO were eucalyptol (27.2%), α-terpinenyl acetate (10.2%), linalool (8.4%), methyleugenol (5.4%), sabinene (4.0%) and carvacrol (3.2%). The EO exhibited strong antibacterial activity against all tested foodborne spoilage and pathogenic bacteria, whereas this activity was less pronounced or even nonexistent in the EE and AE. In contrast, EO exhibited low antioxidant activity compared to extracts (EX), and among the EX, the hot AE revealed the highest antioxidant ability. The results show that bay laurel EO and its EX have potential as natural alternatives to synthetic food preservatives, in order to enhance food safety and increase food shelf life.

Late-night salivary cortisol for diagnosis of overt and subclinical Cushing's syndrome in hospitalized and ambulatory patients

CONTEXT

Neither precise evaluation of pertinent thresholds nor comparison of the diagnostic performance of late-night salivary cortisol (NSC) between inpatient and outpatient settings has been conducted. The usefulness of NSC for the screening of "subclinical" Cushing's syndrome is still unknown.

OBJECTIVES

The aim of the study was to compare the influence of inpatient and outpatient settings on the diagnostic performance of NSC and assess its usefulness as a screening test for subclinical Cushing's syndrome.

DESIGN

Consecutive patients were investigated prospectively with two salivary collections, first as inpatients and then as outpatients.

PARTICIPANTS

Forty-two obese subjects participated in the study, as well as nine patients cured of Cushing's disease, 13 with overt Cushing's syndrome, 14 showing mild recurrence of Cushing's disease, and 48 with adrenal incidentalomas [23 subclinical cortisol-secreting adenomas (SCSA), 25 nonsecreting adenomas].

MAIN OUTCOME MEASURES

Reproducibility of NSC and diagnostic performance were measured using receiver operating characteristic analysis.

RESULTS

NSC in controls was similar between inpatient and outpatient settings. The diagnostic performance of NSC across the different patient groups was similar irrespective of the setting. A threshold of 12 nmol/liter yielded 100% sensitivity and specificity in overt Cushing's syndrome. Optimal performance in subclinical Cushing's syndrome required lower thresholds. NSC showed acceptable performance in diagnosing recurrence of Cushing's disease (90% sensitivity, 91.8% specificity). On the contrary, NSC was similar between patients with SCSA and nonsecreting adenomas.

CONCLUSIONS

Our data validate the outpatient bed sampling strategy for NSC with no need for specific outpatient threshold. NSC may be helpful to detect mild recurrence of Cushing's disease after surgery but is of little value in identifying SCSA amongst adrenal incidentalomas.

Conjugated linoleic acid in diets for large-size rainbow trout (Oncorhynchus mykiss): effects on growth, chemical composition and sensory attributes

The effects of graded levels (0 %, 0·5 %, 0·75 and 1 %) of dietary conjugated linoleic acid (CLA) were assessed on 97 g rainbow trout. Fish were fed to satiation twice a day for 12 weeks. At the end of the experiment, all groups of fish weighed more than 250 g and no significant differences were detected in growth performance, feed conversion, nutrient or energy utilisation or body composition between treatments. A decrease in liver lipid content resulted from including CLA and was accompanied by a reduction in malic enzyme activity. The muscle saturated acid and PUFA content did not vary between dietary treatments, despite the increasing concentration of stearic acid and CLA. In the liver, however, both fractions increased significantly with dietary CLA. Moreover, the MUFA decreased significantly in both muscle and liver. CLA was incorporated into tissue lipids, with levels in flesh (2·1–4·2 %) being 2-fold higher than in liver (0·8–1·9 %). In muscle, the percentage of cis-9, trans-11 isomer ranged from 39·5 % to 41·8 % and that of trans-10, cis-12 isomer from 31·4 % to 33·4 % of total CLA. The incorporation of CLA isomers in the liver varied with dietary treatment, and the cis-9, trans-11 isomer seemed to be more efficiently incorporated than trans-10, cis-12. Sensory data indicated slight-to-moderate differences between the trout fed with and without CLA. The present results suggest that 250 g rainbow trout can incorporate CLA in both muscle and liver, contributing to the production of a functional food.

Assessment of the essential element and heavy metal content of edible fish muscle

The aim of this work was to determine the concentrations of some essential and toxic elements in the muscle of ten species of commercial fish consumed in Portugal. We combined two different techniques for determination of the elements--energy-dispersive X-ray fluorescence (EDXRF) was used to quantify K, Ca, Fe, Zn, Se, Rb, and Sr and flame atomic-absorption spectrometry for analysis of Cr, Ni, Cu, Cd, Hg, and Pb. The latter technique was used because of its higher sensitivity, because these elements were not detected by EDXRF. The results obtained show a similar pattern for the trace elements. K and Ca are present at the highest concentrations in all the samples studied, from 0.6-1.3% and from 0.04-0.08%, respectively, followed by Zn, Fe, Sr, Se, and Rb. Sr is present at higher concentrations than Rb in all the species studied except meagre. Concentrations of the elements in octopus do not follow this pattern--Fe is present at a higher concentration than Zn. Low concentrations of Cr (0.66-1.5 microg g(-1)), Ni (0.11-0.24 microg g(-1)), Cd (0.01-0.08 microg g(-1)), Hg (0.49-2.74 microg g(-1)), and Pb (0.02-0.06 microg g(-1)) were observed in all the samples analysed. The concentration of Hg was highest in Helicolenus dactylopterus--5.4 microg g(-1) in one sample.

Changes in tissue biochemical composition and energy reserves associated with sexual maturation in the ommastrephid squids Illex coindetii and Todaropsis eblanae

The aim of this study was to investigate the biochemical changes that occur during sexual maturation of the squids Illex coindetii and Todaropsis eblanae. In both species, amino acids and protein content increased in the gonad throughout maturation, but the allocation of these nitrogen compounds from the digestive gland and muscle was not evident. A significant (P < 0.05) increase in the content of lipids and fatty acids was observed in the gonad and digestive gland. It seems that both species take energy for egg production directly from food, rather than from stored products. Analyses for cholesterol revealed a significant (P < 0.05) increase in the gonad, and the lipid content differences between species are potentially related to different feeding ecologies. The glycogen reserves in the gonad increased significantly (P < 0.05), suggesting that glycogen has an important role in the maturation process. It was evident that sexual maturation had a significant effect upon the gonad energy content, but because the energy variation in the digestive gland and muscle was nonsignificant (P > 0.05), there was no evidence that storage reserves are transferred from tissue to tissue.

Changes in amino acids and lipids during embryogenesis of European lobster, Homarus gammarus (Crustacea: Decapoda)

We studied the amino acid and lipid dynamics during embryogenesis of Homarus gammarus. Major essential amino acids (EAA) in the last stage of embryonic development were arginine, lysine and leucine; major nonessential amino acids (NEAA) were glutamic acid, aspartic acid, valine and glycine. The highest percent of utilization occurred in respect to EAA (27.8%), mainly due to a significant decrease (p<0.05) of methionine (38.3%) and threonine (36.0%). NEAA also decreased significantly (p<0.05, 11.4%), namely serine (38.1%), tyrosine (26.4%) and glutamic acid (25.7%). In contrast, the free amino acid content increased significantly (p<0.05) during embryonic development, especially the free nonessential amino acids (FNEAA). In the last stage, the most abundant FNEAA were glycine, proline, alanine and taurine, and the major free essential amino acids (FEAA) were arginine, lysine and leucine. Lipid content decreased significantly (p<0.05) during embryonic development. A substantial decrease in all neutral lipid classes was observed (>80% of utilization). Major fatty acids were 16:0, 18:0, 18:1n-9, 18:2n-6, 18:3n-3, 20:5n-3 and 22:6n-3. Unsaturated (UFA) and saturated fatty acids (SFA) were used up at similar rates (76.5% and 76.3%, respectively). Within UFA, monounsaturates (MUFA) were consumed more than polyunsaturates (PUFA) (82.9% and 67.5%, respectively).

Biochemical dynamics of spermatogenesis and oogenesis in Eledone cirrhosa and Eledone moschata (Cephalopoda: Octopoda)

The effect of spermatogenesis and oogenesis on protein, lipid, glycogen, cholesterol and energy contents, total amino acid and fatty acid profiles of Eledone cirrhosa and Eledone moschata tissues (gonad, digestive gland and muscle) was investigated. A significant (p<0.05) increase in the amino acids and protein content of the gonad throughout sexual maturation (namely in oogenesis) was observed, but the allocation of these nitrogen compounds from the digestive gland and muscle was not evident. The major essential amino acids (EAA) in the three tissues were leucine, lysine and arginine. The major nonessential amino acids (NEAA) were glutamic acid, aspartic acid and alanine. A significant increase in lipid and fatty acid contents of gonad and digestive gland was observed. There was also little evidence of accumulated lipid storage reserves being used for egg production. It seems that for egg production Eledone species use energy directly from food, rather than from stored products. Most of saturated fatty acid (SFA) content of the three tissues was presented as 16:0 and 18:0, monounsaturated fatty acid (MUFA) content as 18:1 and 20:1 and polyunsaturated fatty acid (PUFA) content as 20:4n-6, 20:5n-3 and 22:6n-3. Cholesterol and glycogen contents significantly increased in gonad and digestive gland throughout maturation while the muscle revealed no obvious pattern. If Eledone's component sterols are of a dietary origin, a considerable variation in the cholesterol content between species might be expected on the basis of the sterol composition of their prey. Although spermatogenesis and oogenesis had a significant effect (p<0.05) in gonad and digestive gland energy content, the biochemical composition of digestive gland and muscle may not be primarily influenced by sexual maturation, but rather by other biotic factors such as feeding activity, food availability, spawning and brooding.

Nutrition and brain function: a multidisciplinary virtual symposium

A few months ago, the Brazilian Society for Neuroscience and Behavior (SBNeC) promoted a "virtual symposium" (by Internet, under the coordination of R.C.A. Guedes) on "Nutrition and Brain Function". The discussions generated during that symposium originated the present text, which analyzes current topics on the theme, based on the multidisciplinary experience of the authors. The way the brain could be non-homogeneously affected by nutritional alterations, as well as questions like early malnutrition and the development of late obesity and hormone abnormalities were discussed. Also, topics like the role of essential fatty acids (EFAs) on brain development, increased seizure susceptibility and changes in different neurotransmitters and in cognitive performance in malnourished animals, as well as differences between overall changes in nutrient intake and excess or deficiency of specific nutrients (e.g. iodine deficiency) were analyzed. It was pointed out that different types of neurons, possibly in distinct brain structures, might be differently affected by nutritional manipulation, including not only lack-but also excess of nutrient intake. Such differences could help in explaining discrepancies between data on humans and in animals and so, could aid in determining the basic mechanisms underlying lesions or changes in brain function and behavior.

[Neurochristopathy in the differential diagnosis of newborn's apnea: case report]

OBJECTIVE

to include neurocristopathy on the etiological workup of neonatal apneas and discuss the importance of polysomnography in this diagnosis.

METHOD

case report and critical review of the literature.

RESULTS

we report on a newborn that presented respiratory failure in the first hours of life associated to abdominal distention. Continuous ventilatory support was necessary, and the respiratory distress increased during sleep. After polysomnographic confirmation of hypoventilation the newborn was submitted to neuroradiolgic tests and colon byopsy, positive to Hirschsprung's disease.

CONCLUSION

Neurocristopathy syndrome can have many different clinical expression, and sometimes the syndrome can be misdiagnosed. Polysomnography confirms central hypoventilation. This diagnosis should be considered in the newborn's persistent apnea workup.

[Seizures in the neonatal period]

OBJECTIVE: To characterize and differentiate neonatal seizures from those that occur at different ages, based on a critical assessment of the available literature and also on the authorś clinical experience. SOURCES: Literature review, including up-to-date and classical studies that helped us to better understand clinical, neurophysiological and physiopathological aspects related to seizures in the newborn. SUMMARY OF THE FINDINGS: The authors present clinical and electroencephalographic characteristics of neonatal seizures, discuss their classification, treatment and prognosis. CONCLUSIONS: Neonatal seizures have a distinct clinical pattern, which justifies the necessity of an appropriate classification. The etiology is predominantly symptomatic and multifactorial; the treatment should follow a routine protocol, and the prognosis seems to be closely related to etiology.

Cerebral aneurysmal dilatation in an infant with perinatally acquired HIV infection and HSV encephalitis

Although most children with human immunodeficiency virus (HIV) infection have neurological dysfunction, in childhood the incidence of symptomatic cerebrovascular disease is low. Cerebral aneurysmal arteriopathy in childhood AIDS has been reported in the past and considered to have a relatively long latency following the primary infection. We report a 1 month-old infant with congenitally acquired HIV infection, and herpes encephalitis; she presented a sudden cardiorespiratory arrest followed by coma and was found to have a giant saccular aneurysm of the left basilar artery. Literature review showed that cerebral aneurysmal artheriopathy is an unusual manifestation in newborns and infants and this case is possibly the youngest patient reported with aneurysma, herpes encephalitis and AIDS. The role of HIV and herpes simplex infections in the pathogenesis of this lesion is discussed.

Malnutrition increases dentate granule cell proliferation in immature rats after status epilepticus

PURPOSE

Nutritional insults early in life have a profound and often permanent effect on the development of the central nervous system. A direct relationship between malnutrition and epilepsy has not been established; however, it is believed that inadequate nutrition may predispose the brain to seizures. This study was designed to determine whether neonatally malnourished rats are different from nourished rats in terms of flurothyl seizure susceptibility at postnatal day (P)15, in the behavioral manifestations of seizures, and in status epilepticus-induced hippocampal injury.

METHODS

Sprague-Dawley rat pups were maintained on a starvation regimen from P2 until P17. Age-matched control rats were not exposed to starvation. At P15, all animals were exposed to flurothyl-induced status epilepticus. At P17, the rats received a single injection of bromodeoxyuridine (50 mg/kg intraperitoneal) to determine the extent of genesis of new cells in the dentate gyrus. At P18, the rats were killed, and the brains were processed for histology and immunohistochemistry.

RESULTS

Preliminary analysis indicates that early malnutrition did not modify flurothyl seizure susceptibility or the behavioral manifestations of seizures at P15. Histological assessment did not reveal any evidence of hippocampal cell loss after status epilepticus in either group. Malnutrition per se induced an increase in the genesis of new cells in the anterior dentate granule cell layer. Although exposure to status epilepticus augmented the expression of new cells in the dentate gyrus in both groups, this expression was more pronounced in the malnourished group.

CONCLUSIONS

The findings suggest that malnutrition early in life alters dentate plasticity but not the susceptibility to flurothyl seizures. Although status epilepticus can increase the expression of new cells in the dentate gyrus in immature rats, malnutrition followed by status epilepticus further increases dentate granule cell proliferation.

Polysomnography in neonatal seizures

Seizures are one of the most frequent problems in the neonatal period, and are frequently associated with high mortality and morbidity rates. On the other hand, neonatal seizures may represent a first or even the only sign of central nervous system dysfunction. However, establishing the diagnosis of neonatal seizures poses several problems, and clinical observation is not sufficient in many cases. Neonatal polysomnography is a valuable tool both in the diagnostic and in the prognostic assessment of neonatal seizures. The present text reviews some technical aspects related to neonatal polysomnographies, and its usefulness in the area of suspected neonatal seizures. Moreover, some questions are raised regarding rhythmic discharges and their significance as a possible ictal and interictal epileptic pattern in the neonate.

Duration of rhythmic EEG patterns in neonates: new evidence for clinical and prognostic significance of brief rhythmic discharges

OBJECTIVE

This study aimed at identifying the characteristics - especially the duration - of rhythmic discharges in neonatal EEG, and their association with clinical neonatal problems. Specifically, we aimed at testing the diagnostic and prognostic validity of using 10 s as minimal duration for defining electroencephalographic seizures.

DESIGN AND METHODS

The polysomnographies of 340 neonates were reviewed, and episodes of rhythmic discharges were identified, analyzed, and quantified. The study sample was divided into 3 groups: one in which the maximal duration of rhythmic discharges was shorter than 10 s (brief rhythmic discharges, BRD), a second one in which there were rhythmic discharges longer than 10 s (long rhythmic discharges, LRD), and finally a group in which no rhythmic discharge was found (No-RD). These 3 groups of subjects were compared for the baseline and outcome clinical data.

RESULTS

From the 340 neonates studied, 210 did not present any form of rhythmic discharge, 67 (19. 7%) had only BRD episodes, and 63 (18.5%) had at least one LRD episode. Prevalence of rhythmic discharges was low among healthy full term newborns, and was significantly higher among preterm and high-risk newborns. Electrophysiological characteristics of rhythmic discharges did not differ between healthy neonates and high-risk ones. Accompanying clinical manifestations were present in 26.3% of the LRD group, but also in 15.9% of the BRD group. The presence of BRD was significantly associated with leukomalacia and with hypoglycemia in the cross-sectional analysis of baseline data, and with an increased risk for abnormal neurodevelopmental outcome after a mean follow-up period of 47 months (adjusted relative risk=4.90, P<0.01).

CONCLUSIONS

The present data demonstrate an association between BRD and clinical history of hypoxic-ischemic encephalopathy, especially when complicated by leukomalacia, and also with a prognosis of increased risk for abnormal neurodevelopmental outcome. The clinical and prognostic significance of isolated BRD justifies the need to include these brief episodes in future studies of neonatal seizures.

Differences in the dynamics of frontal sharp transients in normal and hypoglycemic newborns

OBJECTIVE

This study focuses on the characteristics of frontal sharp transients (FST), a normal variant of neonatal EEG, in newborns with hypoglycemia.

METHODS

The EEG from 20 newborns with symptomatic hypoglycemia were compared with a control group of normal newborns matched by conceptional age. The dynamics of these transients were evaluated concerning sleep stages. The density, type and bilateral synchrony of FST were also calculated. The results were compared in the two groups by Student's t test.

RESULTS

When compared with controls, hypoglycemic newborns have increased density of frontal sharp transients in all sleep stages but less bilateral synchrony (P<0.05). FST density was even higher in small for gestational age newborns.

CONCLUSIONS

The data suggests that normal patterns of neonatal EEG as FST can be influenced by systemic disturbances.

Congenital intramedullary tumor with neonatal manifestations

The authors report on a 45-day-old boy with a congenital intramedullary tumor with clinical manifestations since birth. Neurologic examination disclosed severe bilateral lower-limb hypotonia and diplegia, with exacerbated deep tendon reflexes and clonus associated with severe pain at manipulation. Further evaluation of this patient included screening for infections, computed tomographic scan, myelography, and somatosensory evoked potentials. The definite diagnosis was a solid holocord astrocytoma. This report discusses a rare disorder in the neonatal period and makes other medical practitioners aware of this diagnosis. Previously published literature is also reviewed.

Subacute sclerosing panencephalitis. Clinical aspects and prognosis. The Brazilian registry

Subacute sclerosing panencephalitis (SSPE) is an inflammatory neurodegenerative disease related to the persistence of measles virus. Although its frequency is declining because of measles eradication, we still have some cases being diagnosed. With the aim to describe epidemiological aspects of SSPE in Brazil, we sent a protocol to Child Neurologists around the country, 48 patients were registered, 27 (56%) were from the southeast region, 34 (71%) were male and 35 (73%) white, 27 (56%) had measles, 9 (19%) had measles and were also immunized, 7 (14%) received only immunization, 1 patient had a probable neonatal form. Mean time between first symptoms and diagnosis was 12 months (22 started with myoclonus or tonic-clonic seizures, 7 (14%) with behavioral disturbances); 36 patients (75%) had EEG with pseudoperiodic complexes. Follow up performed in 28 (58%) patients showed: 12 died, 2 had complete remission and the others had variable neurological disability. Our data shows endemic regions in the country, a high incidence of post-immunization SSPE and a delay between first symptom and diagnosis.

Association of misoprostol, Moebius syndrome and congenital central alveolar hypoventilation. Case report

We report a case showing the association of Moebius syndrome, the use of misoprostol during pregnancy and the development of central congenital alveolar hypoventilation. Pathophysiological aspects of these three diseases are discussed and also the unfavorable prognosis of this association.

[Associated and prognosis in apparent life threatening events (ALTE)]

OBJECTIVE: To verify the etiology and prognosis of ALTE in infancy and its possible relationship to Sudden Infant Death Syndrome (SIDS). METHODS: We studied a group of infants that presented ALTE episodes and were evaluated in our hospital. First we reviewed their clinical history and polysomnographies, then we sent a letter to the families with questions regarding the outcome. RESULTS: 56 patients were included. 92% had ALTE during their first 6 months and 83% in the first trimester. Symptomatic ALTE predominated (71%). The disease most frequently associated was gastroesophageal reflux, followed by neurological diseases. The follow up showed 51.5% of normal outcome, 4 children repeated ALTE, no cases of SIDS were registered. CONCLUSIONS: Our results showed that multifactorial etiologies can be associated to ALTE, and the outcome is generally related to the associated disease. We did not observe any relationship between ALTE and SIDS considering a predominantly symptomatic ALTE population.

Vigabatrin in refractory childhood epilepsy. The Brazilian Multicenter Study

Children, 47, with various types of severe drug-resistant epilepsy were entered into a prospective, add-on, open trial with vigabatrin. Patients with West syndrome and idiopathic generalized epilepsies were excluded. Seven children had the drug withdrawn, five because of increase in seizure frequency and two because of adverse effects. Drug efficacy, measured according to seizure type, showed a 100% decrease in seizure frequency in 18.6% of partial seizures and 17.3% of the generalized seizures. There was a higher than 50% decrease in 39.5% of partial and 60.8% of generalized seizures, and less than 50% decrease or increase in seizure frequency in 41.8% and 21.8% of partial and generalized seizures, respectively. Vigabatrin mean dosage during phase 3 was 63.6 mg/kg per day (S.D. = 30.5), ranging from 19.3 to 110.5 mg/kg per day. Parametric statistical analysis (Student's t-test) of seizure frequency between phases 1 and 3 showed a significant decrease in seizure frequency for partial (P = 0.022), and generalized seizures (P < 0.0001). Drug-related adverse effects were observed in 18/47 cases (38.3%), consisting mainly of irritability, hyperactivity, dizziness, somnolence and gastrointestinal symptoms.

[Phasic activity of REM sleep in newborns and infants and its relationship with apnea episodes]

When the apnea hypothesis turned to be an explanation for sudden infant death syndrome (SIDS) many authors tried to find if near-miss or apparent life-threatening events (ALTE) could be markers of SIDS. It was suggested that phasic REM activity is associated with increased respiratory neuron activity and prevents prolonged apnea in near-miss SIDS. In a previous retrospective study with newborns we did not confirm these results, nevertheless we had several babies with serious neurological disturbances. The aim of this study was to verify the relationship of phasic activity (rapid eyes movement and sucking bursts) with both apneic and non-apneic epochs during REM sleep. We studied 86 children referred for evaluation because they presented an ALTE during sleep or apneas. The subjects were divided in three groups by age (newborns, n = 31; 1-6 months, n = 48; and > 6 < 12 months, n = 7). They were all submitted to a clinical and neurological evaluation in order to detect possible etiological factors to the apneic episode. The polysomnograms (PS) consisted of EEG, submental EMG, electro-oculogram and cardiorespiratory monitoring. The records were made between 11 am and 15 pm for 2 or 3 hours. The electrodes were disposed in the 10-20 system. During one five-minutes epoch of REM sleep we verified the incidence of phasic activity (rapid eyes movement or sucking bursts) time locked to apneic episodes and compared with a similar duration non-apneic epoch. To evaluate the relationship of phasic activity with apneic and non-apneic eopchs we compared the incidence of rapid eyes movements and sucking bursts in each group. Our results showed that phasic activity of REM sleep (sucking bursts) seems to be more frequent in newborns in non-apneic epochs (p < 0.05). Between 1-6 months the number of rapid eyes movements were more frequent in non-apneic epochs (p = 0.001). In conclusion our findings suggest that phasic activity of REM sleep seems to be more evident in nonapneic epochs during the first six months of life. Although central apneas may have their origin in an intrinsic disturb of the respiratory control center they may be influenced by the phasic activity of REM sleep. The rapid eyes movements and sucking bursts may have a protection effect against apneas at least in the first 6 months of life. which is the predominant period for SIDS. We suggest that the excitatory driving related to generation of phasic activity in REM sleep may block or atenuate tonic inhibition of respiratory motoneuron and avoid apnea. It is still open for discussion the possible relation between failure of this protective mechanism and SIDS.

Polysomnographic quantification of bioelectrical maturation in preterm and fullterm newborns at matched conceptional ages

We analyzed the relationship between normal neonatal EEG features and gestational age and conceptional age, and evaluated the normal aspects of EEG maturation in preterm babies compared to term babies. We report 46 newborns, divided into two groups. Group I consisted of 11 newborns with gestational age between 30 and 32 weeks, followed with weekly polysomnograms until they reach 42 weeks' conceptional age. Group II (control) consisted of 35 newborns with gestational ages of 34 weeks (n = 5), 36 weeks (n = 10), 38 weeks (n = 10) and 40 weeks (n = 10) evaluated with one polysomnogram in their first 24-48 h of life. In each examination one 5 min epoch in REM and NREM sleep was analyzed to quantify the number of delta brushes, the presence of frontal and temporal sharp transients, the presence of delta frontal rhythmic activity, the grade of concordance between EEG patterns and sleep stages, the percent of interhemispheric synchrony and the duration of interburst interval. The age dependent variability of the EEG patterns was evaluated during the subsequent weeks with group comparisons at weeks 34, 36, 38 and 40. Our results show that the number of delta brushes and the duration of the interburst interval decrease as gestational and conceptional age increase. The percent of interhemispheric synchrony increases with gestational and conceptional age. The presence of frontal sharp transients and delta frontal rhythmic activity suggest that the newborn is fullterm. The presence of temporal sharp transients suggest a preterm newborn. The degree of concordance between behavioral sleep patterns and EEG was more helpful in recognizing sleep stages than in estimating gestational or conceptional age. Although the EEG patterns were comparable between the groups at the same age, analyses of the behavioral patterns of concordance in NREM sleep showed that newborns in Group I had a more immature behaviour than newborns in Group II. Our results also suggest that extrauterine life of preterm babies does not seem to accelerate EEG maturation but may influence the acquisition of behavioral patterns during NREM sleep.

Developmental regulation of regional functionality of substantial nigra GABAA receptors involved in seizures

GABAergic (gamma-aminobutyric acid) transmission in the substantia nigra pars reticulata is critical for seizure control. We tested the hypothesis that there is a differential regional distribution and functionality of nigral GABAA receptor sites that is developmentally regulated. In adult rats, we determined the effects on flurothyl seizures of (Z)-3-[(aminoiminomethyl)thio]prop-2-enoic acid (ZAPA, a presumed agonist of the low-affinity GABAA receptor site), bicuculline (an antagonist of the low-affinity GABAA receptor site) and gamma-vinyl-GABA (a GABA-transaminase inhibitor), infused bilaterally in anterior or posterior substantia nigra pars reticulata. ZAPA infusions (8 micrograms) were anticonvulsant in anterior substantia nigra but proconvulsant in posterior substantia nigra. Bicuculline infusions (100 ng) were proconvulsant in anterior substantia nigra but ineffective in posterior substantia nigra. An anticonvulsant dose of gamma-vinyl-GABA, when infused in anterior substantia nigra, was proconvulsant when infused in posterior substantia nigra. In 15 day old rats, the effects of ZAPA, were biphasic: 2 micrograms was anticonvulsant while 8 micrograms was proconvulsant. There was no regional specificity. The data suggest that with maturation there is functional segregation of specific GABAA receptor subtypes involved in substantia nigra-mediated seizure control.

Trihexyphenidyl and isoprinosine in the treatment of subacute sclerosing panencephalitis

Six cases of subacute sclerosing panencephalitis (1 stage I, 3 stage II, 2 stage III) were diagnosed at our institution in the last 10 years. Five patients were treated with isoprinosine and the antiepileptic drug valproic acid. Three patients presented with myoclonic seizures refractory to valproic acid and the usual antiepileptic therapy. They received trihexyphenidyl with good results. We suggest the use of trihexyphenidyl in combination with isoprinosine in patients with subacute sclerosing panencephalitis with myoclonic seizures refractory to valproic acid.

[Value of EEG in the characterization and prognosis of neurological diseases in premature infants]

The importance of the EEG for the investigation of neurological diseases in the neonatal period has been largely discussed, since it is often the only way to approach cerebral function in newborns with severe pathologies or under drug effect. The present study was carried out with 85 newborns (NB) who presented perinatal dysfunctions and were submitted to neurological and electroencephalogram (EEG) or polysomnography (PS) evaluation. EEG/PS alterations, pathologies and prognosis were reported. The EEG were classified according to basal activity alterations, presence of paroxysmal activity and sleep stages organization and maturity. The most frequent pathology was perinatal asphyxia (40%) followed by intraventricular hemorrhage (HIV, 16%). The most frequent complaint for exam indication was apnea (71%) followed by convulsion (19%). Fifty-five percent of the exams exclusively required because apnea complaint were considered normal and out of all exams required because seizures only 31% were normal. The EEG alteration most frequently related to perinatal asphyxia, HIV and intrauterine growth delay was immaturity and in the NB with seizures immature EEG and abnormal paroxysms. Many different alterations were registered in the NB with nervous system infection. The EEG findings more correlated with unfavorable prognosis were isoelectricity and abnormal paroxysmal activity including positive sharp waves (100%).

Early onset bilateral calcifications and epilepsy

Bilateral occipital calcifications associated with epilepsy and sometimes with celiac disease have been described previously. A boy with bilateral frontal and occipital diffuse calcifications accompanied by failure to thrive, nephrogenic diabetes insipidus, developmental delay and seizures, but without celiac disease is presented. Follow-up at 3 years of age disclosed neurodevelopmental delay, height and weight less than expected for age, and seizures controlled with carbamazepine. The uncommon association of these features and the early onset of symptoms is discussed. Although bilateral occipital calcifications share some clinical features with bilateral fronto-occipital calcifications, it is arguable whether the two are on a spectrum of a single disease or represent separate entities.