Elevated and sustained anti-feeding effect of Scalibor® deltamethrin collar against the sand fly Phlebotomus perniciosus in dogs confirmed for 1 year following treatment

Dogs are reservoir hosts for Leishmania infantum, a protozoan parasite transmitted by phlebotomine sand flies. The anti-feeding and fast-killing efficacy of Scalibor® deltamethrin collars against experimental Phlebotomus perniciosus challenges on dogs was determined over 1 year. Two groups of 8 dogs each were fitted with placebo (control) or deltamethrin collars (treated) on Day 0 and exposed to sand flies approximately every 28 days up to Day 364. After each exposure, anti-feeding and fast-killing efficacy rates were determined by comparing blood-fed or live insects, respectively, in the treated vs. the control group. Blood-fed and live sand flies were significantly less in treated dogs as compared to control dogs at each assessment. The anti-feeding efficacy rate exceeded 90% except on Day 337 (89%) but increased again (96%) on Day 364. Fast killing efficacy was <74% over the study when considering all flies. However, this value increased cumulatively to 98% when only blood-fed flies were compared between groups. Scalibor® collars are highly effective at preventing P. perniciosus blood-feeding and in fast-killing flies taking a blood meal for up to 1 year after application. These strong and long-lasting effects are an important strategic component for L. infantum transmission control.

Laboratory evidence that dinotefuran, pyriproxyfen and permethrin combination abrogates Leishmania infantum transmissibility by sick dogs

Dogs are reservoir hosts of leishmaniasis caused by Leishmania infantum and transmitted by phlebotomine vectors. The effect of dinotefuran, pyriproxyfen and permethrin spot-on solution (Vectra®3D, Ceva Santé Animale, Libourne, France) on Leishmania transmissibility by naturally infected dogs via reared Phlebotomus perniciosus, was assessed. Dogs affected by leishmaniasis were submitted to xenodiagnosis and 6 infecting >10% of insects were treated topically on day 0. Antifeeding, insecticidal and anti-transmissibility effects were evaluated through xenodiagnoses performed on days 1, 7 and 28, using individual pre-treatment parameters as control. Feeding and mortality rates were assessed at 24 h, whereas promastigote infection, maturation and burden were assessed up to 96 h post blood meal (potentially infectious rate). On day 1, the anti-feeding efficacy was >95% in 4 dogs, insecticidal efficacy 100% in 4 dogs, and anti-transmissibility effect 100% in 6 dogs. Efficacy rates recorded on day 7 were very similar to day 1. On day 28, anti-feeding and insecticidal efficacy values were much broader, ranging 32.6-100% and 7.7-94.4%, respectively. Potentially infectious insects were recorded from two dogs, with sharp decrease in transmissibility rate as compared with pre-treatment condition. Altogether, Vectra®3D abrogated by >98% the potential Leishmania transmissibility by the examined pool of infected dogs over 1 month.

Myocardial work evaluation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Background

myocardial work (MW) is a novel echocardiographic technique which assesses left ventricular (LV) performance through LV pressure-strain loops. MW corrects speckle tracking echocardiography (STE)-derived parameters for afterload using non-invasive systolic blood pressure (SBP) as a surrogate for LV systolic pressure. In patients with severe aortic stenosis (AS), the corrected MW (cMW) has been proposed, consisting in adding the mean aortic gradient in SBP. This method revealed to be feasible and reliable, demonstrating good correlation with invasively measured LV systolic pressure.

Purpose

to evaluate myocardial performance of patients with severe AS, before and after transcatheter aortic valve implantation (TAVI), by MW indices.

Methods

patients with severe AS undergoing TAVI were included. Transthoracic, standard echocardiography and STE were performed the day before the procedure and within 2 days after. MW was calculated by combining STE-derived indices with non-invasively estimated LV systolic pressure.

Results

30 patients (79 ± 5 years old, 56% females) with severe AS (mean gradient 47 ± 14 mmHg, aortic valve area 0.6 ± 0.1 cm2), and eligible for TAVI were enrolled. Baseline global longitudinal strain was impaired (GLS -15 ± 4%), in presence of normal LV ejection fraction (LVEF 57 ± 10%). Corrected global work index and global constructive work were preserved at baseline and markedly decreased after TAVI (cGWI 2322 ± 791 vs 1710 ± 505 mmHg%, p = 0.001; cGCW 2774 ± 803 vs 2083 ± 536 mmHg%, p = 0.0007). Corrected global wasted work and global work efficiency were higher than reference values existing in literature, and no significant changes were observed after TAVI (cGWW 276 ± 174 vs 277 ± 165 mmHg%, p = 0.974; cGWE 89 ± 5 vs 87 ± 5%, p = 0.177). A significant inverse correlation was found between baseline cGWI and left atrial volume index (r=-0.5, p = 0.03).

Conclusions

patients with severe aortic stenosis and preserved LVEF show a good LV performance before and after TAVI, with a significant decrease in MW indices after TAVI, because of the reduced afterload due to AS treatment. The negative correlation between left atrial volume and cGWI may reflect the extent of myocardial damage in AS. However, further studies with larger sample size and appropriate follow-up are needed to evaluate the role of MW in prognosis and risk stratification of this subset of patients.

Uncommon suicide methods in the detention regime in Milan (1993-2019): Forensic contribution on autopsy cases

We analysed the recorded cases of suicides committed other than by hanging in prison in Milan. A retrospective analysis was conducted on 25,512 autopsies performed from 1993 to 2019, selecting all the suicides in prison but our attention was focused solely on cases where an alternative mode to hanging was used. From a total of 97 suicide events in prison, 15 were consistent with the established search criteria: 6 victims died from plastic bag suffocation, 4 by direct inhalation of butane gas, 2 associated plastic bag suffocation to inhalation of butane gas, one committed suicide with an edged weapon, one by self-burning and, finally, one by voluntary ingestion of a food to which he was allergic, with the intent of inducing an anaphylactic shock. Our analysis has shown that the landscape of prison suicides is diverse, not limited solely to hanging. Therefore, it is necessary for the forensic scientific community to raise awareness of potentially unusual suicide methods in prisons and, in the same way, for the Penitentiary Administration to put adequate preventive measures and strategies in place.

Postmortem diagnostics of assumed suicidal food anaphylaxis in prison: a unique case of anaphylactic death due to peach ingestion

Suicidal ingestion of food which the victim is aware they are allergic to is an exceptional occurrence in the forensic field. To the best of our knowledge, no cases of suicidal food anaphylaxis have been reported to date. Therefore we present the first case described in the literature. A 30-year-old prisoner was found dead inside his cell with the remains of a peach remains next to his body, and a handwritten farewell note in his pocket. The autopsy revealed only non-specific findings, while laboratory investigations (serological, toxicological, histological, and immunohistochemical) played a pivotal role in determing the cause and manner of death. In particular, a high titer of both total and specific IgE antibodies was detected, as well as an increase of the tryptase level in cadaveric blood. Moreover, a massive concentration of salicylates was measured in the gastric contents. Microscopically, cellular residues characterized by a vegetal structure were observed in the gastric contents and elements suggestive of mast cells were detected in the glottis, lungs, and myocardium. The immunohistochemical investigation with anti-CD117 and anti-tryptase antibodies showed positivity for mast cells, some of which appeared degranulated. Such findings were entirely consistent with an acute systemic anaphylactic reaction triggered by allergy. Therefore, the prisoner’s death was attributed to self-induced food anaphylaxis caused by the ingestion of peaches. This conclusion was achieved based only on circumstantial data, anamnestic information, autopsy findings, and multiple laboratory results. This integrated approach should be used to pursue a post-mortem diagnosis of anaphylaxis.

A novel nomogram predicting lymph node invasion among patients with prostate cancer: The importance of extracapsular extension at multiparametric magnetic resonance imaging

PURPOSE

To develop a novel risk tool that allows the prediction of lymph node invasion (LNI) among patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND).

METHODS

We retrospectively identified 742 patients treated with RARP + ePLND at a single center between 2012 and 2018. All patients underwent multiparametric magnetic resonance imaging (mpMRI) and were diagnosed with targeted biopsies. First, the nomogram published by Briganti et al. was validated in our cohort. Second, three novel multivariable logistic regression models predicting LNI were developed: (1) a complete model fitted with PSA, ISUP grade groups, percentage of positive cores (PCP), extracapsular extension (ECE), and Prostate Imaging Reporting and Data System (PI-RADS) score; (2) a simplified model where ECE score was not included (model 1); and (3) a simplified model where PI-RADS score was not included (model 2). The predictive accuracy of the models was assessed with the receiver operating characteristic-derived area under the curve (AUC). Calibration plots and decision curve analyses were used.

RESULTS

Overall, 149 patients (20%) had LNI. In multivariable logistic regression models, PSA (OR: 1.03; P= 0.001), ISUP grade groups (OR: 1.33; P= 0.001), PCP (OR: 1.01; P= 0.01), and ECE score (ECE 4 vs. 3 OR: 2.99; ECE 5 vs. 3 OR: 6.97; P< 0.001) were associated with higher rates of LNI. The AUC of the Briganti et al. model was 74%. Conversely, the AUC of model 1 vs. model 2 vs. complete model was, respectively, 78% vs. 81% vs. 81%. Simplified model 1 (ECE score only) was then chosen as the best performing model. A nomogram to calculate the individual probability of LNI, based on model 1 was created. Setting our cut-off at 5% we missed only 2.6% of LNI patients.

CONCLUSIONS

We developed a novel nomogram that combines PSA, ISUP grade groups, PCP, and mpMRI-derived ECE score to predict the probability of LNI at final pathology in RARP candidates. The application of a nomogram derived cut-off of 5% allows to avoid a consistent number of ePLND procedures, missing only 2.6% of LNI patients. External validation of our model is needed.

Mortality in Prisons: The Experience of the Bureau of Legal Medicine of Milan (Italy) (1993-2017) : Suicides and natural deaths in prison

We undertook a retrospective analysis of deaths that took place in prisons in Milan between 1993 and 2017, by identifying cases from a total of 24,101 autopsies that were performed at the Section of Forensic Medicine of the University of Milan. From the archives of this institution, we found 227 autopsy reports relating to deaths that had taken place in one of Milan's three detention facilities. These deaths were divided into two types: natural deaths (n=135; 59.5%) and violent deaths (n=92; 40.5%). The groups have different characteristics: while natural deaths mostly resulted from cardiovascular diseases, suicides were mainly the result of hanging. Further, people who died by suicide often had a history of psychiatric disease and/or drug abuse, and over a quarter of them had previous suicide attempts and/or had declared suicidal intentions. This study confirms the need for good quality healthcare services for prisoners, given that they remain a population at high risk of early death.

A single oral dose of fluralaner (Bravecto®) in dogs rapidly kills 100% of blood-fed Phlebotomus perniciosus, a main visceral leishmaniasis vector, for at least 1 month after treatment

Dogs are the reservoir host of zoonotic visceral leishmaniasis (VL) caused by Leishmania infantum (Kinetoplastida: Trypanosomatidae). Both subclinically-infected and sick animals can be infectious to competent phlebotomine vectors. The degree and duration of insecticidal efficacy of an oral dose of fluralaner (Bravecto®; Merck Animal Health) was determined in dogs exposed to bites of Phlebotomus perniciosus (Diptera: Psychodidae), a main Mediterranean vector of VL. Twelve dogs allocated to two groups of six animals each were included in a parallel-group designed, negative-controlled, randomized, blinded, single-centre efficacy study. Group 2 was treated with fluralaner on day 0, and sand-fly exposure of both groups was performed on days 1, 28 and 84. Viability of blood-fed females was assessed up to 96 h after exposure and efficacy was measured as the survival rate of specimens fed on Group 2 versus those fed on Group 1. A mortality of 100% was recorded at 24 h in females fed on Group 2 at both days 1 and 28. Significant insecticidal efficacy was still observed on day 84, with > 50% mortality recorded by 48 h post blood meal in Group 2. Fluralaner treatment of dogs represents a promising and affordable method for reducing the pool of infected vectors in endemic settings of zoonotic VL.

Burnout, depression and paranoid ideation: a cluster-analytic study

Background

A link between burnout and paranoid ideation has long been suspected. However, systematic research on the association has been scarce.

Aims

We investigated the relationship between burnout and paranoid ideation. Because burnout overlaps with depression, depression was also examined.

Methods

A total of 218 Swiss schoolteachers participated in the study (58% female; mean age: 47). Burnout symptoms were assessed with the emotional exhaustion (EE) and depersonalization (DP) subscales of the Maslach Burnout Inventory-Educators Survey, depressive symptoms with the PHQ-9 and paranoid ideation with the Green et al. Paranoid Thought Scales.

Results

Burnout, depression and their subdimensions showed raw correlations ranging from 0.42 to 0.55 with paranoid ideation. Burnout, depression and paranoid thoughts were found to cluster together. Lower levels of burnout and depression coexisted with lower levels of paranoid ideation and higher levels of burnout and depression coexisted with higher levels of paranoid ideation. When corrected for measurement error, the correlations of EE with depression and DP were 0.96 and 0.57, respectively. A principal component analysis confirmed that EE was indistinguishable from depression.

Conclusions

Burnout is substantially associated with paranoid ideation. Interestingly, EE correlated as strongly with paranoid ideation as it correlated with DP. Moreover, if burnout is a syndrome of EE and DP that excludes depression, then the EE-depression correlation should not be close to 1 and EE should not correlate more strongly with depression than with DP. These basic requirements for construct distinctiveness and syndromal unity were not satisfied.

Comparison between prostitutes' and general women's homicides: The experience of the bureau of legal medicine of Milan and Hinterland over 26 years

We present a retrospective study of prostitutes' homicide in the Milanese area over a 26-year period (1993-2018), and compare the results with general women's homicides: 294 women were killed of whom 71 were prostitutes. In the general population, the type-victim is an Italian woman aged between 31 and 40 years suffering from no particular pathologies or drug dependence. Prostitutes are 10 years younger, mostly Italian, suffering from pathologies probably related to their activities. Prostitutes remain at high risk of violence, due to gaps in the crime prevention system.

Detection of Melanoma Cells in Peripheral Blood and Sentinel Lymph Nodes by RT-PCR Analysis: A Comparative Study with Immunohistochemistry

The presence of lymph node metastases is the best prognostic factor for predicting relapse or survival in melanoma patients. It has been demonstrated that melanoma metastases spread through the first lymph node(s) draining the tumor (sentinel lymph node, SN) to the lymphatic system and that detection of melanoma cells in peripheral blood directly correlates with prognosis in melanoma.

To identify lymph node metastases and circulating melanocytes, we developed a single-step reverse transcriptase-polymerase chain reaction assay (RT-PCR) for detection of two melanoma-specific markers: the tyrosinase gene, which encodes an enzyme associated with melanin synthesis, and melanoma antigen-related T-cells, which are present in tumor infiltrating T-lymphocytes. This method detects two tumor cells in a background of 107 lymphocytes.

Thirty patients with stage I–IV cutaneous melanoma entered the study. Blood samples were taken preoperatively, one month after excision of the primary melanoma lesion and the SN or total lymphadenectomy, and before the start of chemotherapy and every three months thereafter in metastatic patients. SNs were collected from 22 patients, bisected and analyzed by RT-PCR and routine pathological and immunohistochemical tests. The preliminary results indicate that RT-PCR for melanoma markers is a sensitive and valuable method for the detection of micrometastases and for early diagnosis and staging of melanoma.

Gamma Probe-Guided Thoracoscopic Surgery of Small Pulmonary Nodules

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5–10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4–19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13–80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.

Empirical Redundancy of Burnout and Depression: Evidence from Time-standardized Measures

Introduction

Burnout and depression are ordinarily assessed within different time frames. Burnout is most frequently assessed on an annual or a monthly basis whereas depression is generally assessed over a one- or two-week period. This state of affairs may have partly obscured the burnout-depression relationship in past research and contributed to an underestimation of burnout-depression overlap.

Objectives

We investigated burnout-depression overlap using time-standardized measures of the two constructs. We additionally examined whether burnout and depression were differently associated with work-related effort and reward, occupational social support, and intention to quit the job.

Methods

We enrolled 257 Swiss schoolteachers (76% female; mean age: 45). Burnout was assessed with the Shirom-Melamed Burnout Measure and depression with a dedicated module of the Patient Health Questionnaire. Work-related effort and reward were measured with a short version of the Effort-Reward Imbalance Scale and occupational social support with a subscale of the Job Content Questionnaire. Intention to quit the job was assessed with 3 generic items (e.g., “I plan on leaving my job within the next year”).

Results

We observed a raw correlation of .82 and a disattenuated correlation of .91 between burnout and depression. Burnout's dimensions (physical fatigue; cognitive weariness; emotional exhaustion) did not correlate more strongly with each other (mean r = .63) than with depression (mean r = .69). Burnout and depression showed similar associations with the job-related factors under scrutiny.

Conclusions

Burnout and depression may be empirically-redundant constructs. Measurement artifacts probably contributed to an underestimation of burnout-depression overlap in many studies.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A Person-centered Approach to Burnout-depression Overlap

Introduction

Burnout has widely infiltrated the popular culture and has been extensively studied in both psychiatry and psychology. However, there are currently no consensual or binding diagnostic criteria for burnout. A major obstacle to the elevation of burnout to the status of nosological category is the overlap of burnout with depression.

Objectives

We examined whether burnout and depressive symptoms can be distinguished from each other using a person-centered approach.

Methods

A total of 1759 French schoolteachers took part in the present study (77% female; mean age: 41; mean length of employment: 15). Burnout symptoms were assessed with the Shirom-Melamed Burnout Measure (14 items) and depressive symptoms with a dedicated module of the Patient Health Questionnaire (9 items). Data were primarily processed using two-step cluster analysis. Correlation analysis and analysis of variance (ANOVA) were additionally carried out.

Results

Considered as continuous variables, burnout and depression were found to be closely intertwined (r = 0.81; disattenuated correlation: 0.91). Our cluster analysis revealed four different participant profiles, identifiable as “minimal burnout-depression” (n = 542; 31%), “low burnout-depression” (n = 566; 32%), “medium burnout-depression” (n = 412; 23%), and “high burnout-depression” (n = 239; 14%). Burnout and depression played equivalently important roles in cluster construction. Our ANOVA confirmed that the four clusters differed from each other in terms of burnout and depressive symptoms.

Conclusions

Our findings are consistent with the view that the burnout syndrome is depressive in nature. A diagnostic category dedicated to burnout may therefore not be needed.

Is it Time to Characterize Burnout as a Depressive Syndrome? A Review of Recent Research

Introduction

More than 40 years after the introduction of the construct in the literature, the status of “burnout” remains unclear. Whether burnout is anything other than a depressive syndrome has been increasingly discussed in recent years.

Objectives

We examined the extent to which burnout can be considered distinct from depression.

Methods

We reviewed the literature dedicated to burnout-depression overlap over the last decade.

Results

Recent research suggests that burnout and depression overlap in terms of (a) etiology, with (chronic) unresolvable stress a common, key causal factor, (b) clinical picture and course, with burnout and depressive manifestations inextricably linked such that they increase or decrease together over time, (c) cognitive biases, with burnout and depressive symptoms similarly predicting increased attention to negative stimuli and decreased attention to positive stimuli, (d) dispositional correlates (e.g, neuroticism, rumination, pessimism), and (e) allostatic load—an index of the biological cost of adaptation to life adversity. Hypocortisolism has been linked to both burnout and depression with atypical features—a highly prevalent form of depression. The often-invoked argument that burnout is singularized by its job-related character is actually invalid given that (a) depression can also be job-related and (b) the “job-relatedness” of a syndrome is not nosologically discriminant in itself.

Conclusions

Robust evidence that burnout overlaps with depression has accumulated in recent years. The burnout construct is unlikely to capture a distinct pathological phenomenon. We propose that burnout be characterized as a depressive syndrome for the sake of conceptual parsimony, theoretical clarity, and effective public health policies.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Monitoring the hospital management of acute asthma: the Italian Pediatric Network experience

BACKGROUND

The Study Group on Accreditation and Quality Improvement of the Italian Society of Pediatrics has developed an observational study about the hospital management of pediatric patients affected by severe asthma, in order to evaluate how the Guidelines for severe asthma in childhood are applied in the daily practice.

METHODS

This study included patients between 2 and 17 years, hospitalized or under short intensive observation for acute asthma. The data collection was carried out through the compilation of on-line forms. The statistical technique used was the Chi Square test.

RESULTS

409 forms were filled in by 32 Italian Centers. 17% of the patients showed severe asthma, 59% moderate and 24% mild. On arrival at the Emergency Room the oximetry was measured in 95% of the patients, the respiratory rate in 64% while the heart rate in 88% of them. 48% of the children were exposed to chest X-ray. More than half of the children received oxygen therapy, 98.5% received short-acting beta-2 agonists and systemic steroid therapy was given to 82% of children, mainly orally. At discharge only half of the children were provided with written instructions for the management of any subsequent asthmatic episode. The analysis of the collected data highlights that not all the children had their oxygen saturation measured, although this parameter is one of the main indicators of disease severity, as well as the respiratory rate, which was detected in a minimal percentage of cases. The frequency of chest X-ray was extremely high, even though it does not have any indication in the majority of asthma cases. The evaluation of the therapeutic treatment denotes an adequate use of the oxygen therapy according to the oximetry values found on arrival, but an abuse of steroid therapy. Critical issues emerge at discharge: children are not always educated about the home management of the disease and the self-evaluation of the illness seriousness.

CONCLUSION

The pediatric network has become an excellent system of monitoring of the clinical management of asthmatic children, highlighting strengths and weaknesses on which to focus actions of improvement.

From intravenous to enteral ketogenic diet in PICU: A potential treatment strategy for refractory status epilepticus

BACKGROUND

Ketogenic diet (KD) has been used to treat refractory status epilepticus (RSE). KD is a high-fat, restricted-carbohydrate regimen that may be administered with different fat to protein and carbohydrate ratios (3:1 and 4:1 fat to protein and carbohydrate ratios). Other ketogenic regimens have a lower fat and higher protein and carbohydrate ratio to improve taste and thus compliance to treatment. We describe a case of RSE treated with intravenous KD in the Pediatric Intensive Care Unit (PICU).

CASE REPORT

An 8-year-old boy was referred to the PICU because of continuous tonic-clonic and myoclonic generalized seizures despite several antiepileptic treatments. After admission he was intubated and treated with intravenous thiopental followed by ketamine. Seizures continued with frequent myoclonic jerks localized on the face and upper arms. EEG showed seizure activity with spikes on rhythmic continuous waves. Thus we decided to begin KD. The concomitant ileus contraindicated KD by the enteral route and we therefore began IV KD. The ketogenic regimen consisted of conventional intravenous fat emulsion, plus dextrose and amino-acid hyperalimentation in a 2:1 then 3:1 fat to protein and carbohydrate ratio. Exclusive IV ketogenic treatment, well tolerated, was maintained for 3 days; peristalsis then reappeared so KD was continued by the enteral route at 3:1 ratio. Finally, after 8 days and no seizure improvement, KD was deemed unsuccessful and was discontinued.

CONCLUSIONS

Our experience indicates that IV KD may be considered as a temporary "bridge" towards enteral KD in patients with partial or total intestinal failure who need to start KD. It allows a prompt initiation of KD, when indicated for the treatment of severe diseases such as RSE.