Which patient benefit most from minimally invasive direct anterior approach total hip arthroplasty in terms of perioperative blood loss? A retrospective comparative study from a cohort of patients with primary degenerative hips

INTRODUCTION

Total hip arthroplasty (THA) is a successful surgery, but despite the advancements in anesthesiology and orthopedics, sometimes blood transfusions are required to manage the anemia due to the blood loss, involving a substantial number of patients. The aim of this retrospective comparative study is to define how the choice of the surgical approach, either direct anterior (DA) or posterolateral (PL), may influence the postoperative blood loss and the need for transfusion in THA.

MATERIALS AND METHODS

Data collection was carried out retrospectively of THAs performed between 2016 and 2021 on primary hip osteoarthritis treated by DA or with PL approach. Clinical and perioperative anesthetic data were collected. Preoperative hemoglobin levels were compared with the lowest detected level by calculating ΔHb (hemoglobin decrease). Then, data from the two groups were cross-checked: duration of surgery, whether premedication with tranexamic acid, duration of the hospitalization, rate of need for hemotransfusions, and amount of blood transfused. The two samples were subdivided into subgroups according to age, BMI, tranexamic acid prophylaxis, and chronic treatment with drugs that alter coagulative properties.

RESULTS

Time of surgery was longer for patients treated with DA access (mean DA: 78.8 min; mean PL: 74.8 min; p: 0.05; 95% CI), but the length of hospitalization was shorter for patients treated with DA group with a mean time of 6.23 days versus 7.12 days for the PL group (p < 0.01). DA THA resulted advantageous mainly in patients between 66 and 75 years, showing a reduced postoperative transfusion requirement in the postoperative period (DA: 13.43%-mean: 1.33 units; PL: 26.82%-mean: 1.18 units; p: 0.044, 95% CI). Patients that assume blood-altering drugs showed a higher transfusion rate (p < 0.01), but comparison of the two subgroups showed that the choice of the surgical approach did not significantly affect the transfusion rate in these patients (p: 0.512). Prophylaxis with tranexamic acid reduced the transfusion rate (p < 0.01).

CONCLUSION

Patients treated by minimally invasive direct anterior approach undergo a significantly shorter hospitalization. From the analysis of patient's subgroups those aged between 66- and 75-years benefit from the DA approach mainly for the minor blood loss with less frequent transfusion requirement.

Total knee arthroplasty in pigmented villonodular synovitis osteoarthritis: a systematic review of literature

PURPOSE

Pigmented Villonodular Synovitis (PVNS) is a proliferative disease arising from the synovial membrane, mainly affects large joints such as the knee (almost 80% of total). Prostheses implanted in PVNS osteoarthritis show a higher revision rate when compared to primary osteoarthritis, due to the recurrence of disease and the overall surgical complications. The purpose of this systematic review is to summarize and compare indications, clinical and functional outcomes, disease-related and surgical-related complications of total knee arthroplasty in PVNS osteoarthritis.

MATERIALS AND METHODS

A systematic review of the literature was performed with a primary search on Medline through PubMed. The PRISMA 2009 flowchart and checklist were used to edit the review. Screened studies had to provide preoperative diagnosis, previous treatments, main treatment, concomitant strategies, mean follow-up, outcomes and complications to be included in the review.

RESULTS

A total of 8 articles were finally included. Most of papers reported the use of non-constrained design implants, mainly posterior stabilized (PS) and in case of PVNS with extensive joint involvement implants with higher degree of constraint to obtain a fulfilling balancing. Recurrence of PVNS has been indicated as the major complication, followed by aseptic loosening of the implant and difficult post-operative course with an increased risk of stiffness.

CONCLUSION

Total knee arthroplasty represents a valid treatment for patients with PVNS end-stage osteoarthritis, with good clinical and functional results, even in longer follow-up. It would be advisable a multidisciplinary management and a meticulous rehabilitation and monitoring following the procedure, to reduce the emergence of recurrence and overall complications.

Constraint degree in revision total knee replacement: a registry study on 1432 patients

PURPOSE

Total knee replacement (TKR) failure represents a hard challenge for knee surgeons. TKR failure can be managed in revision with different constraint, related with soft and bone knee damages. The choice of the right constraint for every failure cause represents a not summarized entity. The purpose of this study is identifying distribution of different constraints in revision TKR (rTKR) for failure cause and the overall survival.

METHODS

A registry study based on the Emilia Romagna Register of the Orthopaedic Prosthetic Implants (called RIPO) was performed with a selection of 1432 implants, in the period between 2000 and 2019. Selection implants including primary surgery constraint, failure cause and constraint revision for every patient, and divided for constraint degrees used during procedures (Cruciate Retaining-CR, Posterior Stabilized-PS, Condylar Constrained Knee-CCK, Hinged).

RESULTS

The most common cause of primary TKR failure was aseptic loosening (51,45%), followed by septic loosening (29,12%). Each type of failure was managed with different constraint, the most used was CCK in the most of failure causes, such as to manage aseptic and septic loosening in CR and PS failure. Overall survival of TKA revisions has been calculated at 5 and 10 years for each constraint, with a range of 75.1-90.0% at 5 years and 75.1-87.5% at 10 years.

CONCLUSION

Constraint degree in rTKR is typically higher than primary, CCK is the most used constraint in revision surgery with an overall survival of 87.5% at 10 years.

Management of patella maltracking after total knee arthroplasty: a systematic review

PURPOSE

Patella maltracking is among the most frequent causes of poor outcomes and early failure after total knee arthroplasty (TKA), with an incidence that ranges from 1 to 20%. Even if there is agreement between authors regarding the preoperative and intraoperative management of patella maltracking in TKA, less clear are postoperative conducts. The purpose of this systematic review is to summarize and compare surgical techniques used to treat patella maltracking after TKA.

METHODS

A systematic review of the literature was performed with a primary search on Medline through PubMed. The PRISMA 2009 flowchart and checklist were used to edit the review. Screened studies had to provide clinical, functional and radiological results and complications of the proposed treatment to be included in the review.

RESULTS

A total of 21 articles were finally included. Three main types of surgical procedures and other minor techniques have been identified to manage patella maltracking after TKA. The choice of the proper technique to use in the specific case depends on several factors, first of all the malpositioning of the prosthetic components.

CONCLUSION

Patella maltracking after TKA represents a frequent and challenging problem for orthopedic surgeons. Treatments described in the literature are often able to correct an abnormal patellar tracking; nevertheless, authors report variable percentages of residual knee pain and dissatisfaction in re-treated patients. Therefore, it would be desirable to prevent the maltracking condition at the time of primary arthroplasty, using proper surgical precautions.

Total knee replacements using rotating hinge implants in polio patients: clinical and functional outcomes

Little evidences are available in the literature concerning the outcomes of total knee replacement (TKR) in poliomyelitis patients with severe knee deformities or degeneration. Encouraging results have been reported concerning the use of constrained implants, i.e., rotating hinge knee prosthesis (RHK), compared to less constrained ones. The purpose of this paper is to report our experience with rotating hinge total knee replacement, using only RHK prosthesis, to determine functional results, complications, and survival of TKR in poliomyelitis patients. We performed a retrospective chart review of 14 patients with a history of knee osteoarthritis following poliomyelitis that underwent primary TKR, for a total of 15 surgical procedure (one bilateral case). Preoperative and postoperative clinical measurements have been conducted for all patients using the Knee Society Score (KSS). Hip-knee angle, recurvatum knee angle, and Insall-Salvati index were evaluated with full weight-bearing panoramic view X-ray preoperatively and postoperatively. The 2-year postoperative clinical KSS significantly improved from the preoperative scores. The average clinical KSS improved from 32,9 (range 3-48) preoperatively to 77,4 (range 60-88) postoperatively (P value < 0.005). The average functional KSS improved from 32,5 (range 10-60) preoperatively to 59,4 (range 30-95) postoperatively (P value < 0.005). TKR is a successful treatment in improving knee function and patient's quality of life. Using constrained implants, especially rotating hinge implants in polio patients with a quadriceps muscle weakness, could be a good alternative to maintain a physiological kinematics and reducing the revision rate due to knee instability.

Prenatal care utilization in pregnant women who consider but do not have abortions

Background

Over half of all pregnancies in the United States are unintended, and 18% result in termination of pregnancy (TOP). Some women seek TOP, but ultimately continue their pregnancy. Data are limited about their utilization of prenatal care and their perinatal outcomes. Our primary outcome was to investigate differences in guideline-based prenatal care utilization in women who consider but do not have an abortion.

Methods

Retrospective cohort study of patients having obstetrical dating ultrasound (US) from 2011–2018 at a single academic medical center that offers TOP. Contemplators completed US with intention of TOP but instead continued the pregnancy to live birth. A 2:1 group of non-contemplators completed US and continued to live birth. A prenatal care utilization scoring system was used to compare groups. Secondary outcomes investigated differences in adverse pregnancy outcomes and postpartum care.

Results

There were 94 contemplators and 183 non-contemplators. Inadequate prenatal care utilization initially was more common in contemplators than non-contemplators (62.8% vs 85.8%, p < 0.01) but was not significant after adjustment (aOR 1.0, 95% CI 0.40 – 2.56). There were no differences in adverse obstetric or neonatal outcomes. Contemplators were significantly more likely to have a postpartum contraceptive method (PPCM) upon hospital discharge (aOR 4.8, 95% CI 1.16 – 20.0) and significantly more likely to use a highly-effective PPCM (aOR 6.4, 95% CI 2.34 – 17.4).

Conclusions

Reversal of intention for TOP is not associated with differences in prenatal care utilization, but is associated with increased uptake of postpartum contraceptive method.

COVID-19 impact on the health and emotional well-being of the general population

 

A tremendous number of studies describe results on the evolution of the COVID-19 impact on infected patients, hospital admissions, deaths, mental health and well-being of the population. However, there are hardly any reports on its impact and evolution since the beginning of the pandemic with clinical, contextual and individual perception information. Our work describes the research project called Health Care and Social Survey (ESSOC, Encuesta Sanitaria y SOCial). It arises from the need to provide specific, reliable, early, and timely data on the impact of COVID-19 that can be considered when making decisions to prepare and provide an effective Public Health response in the different affected populations. It is linked to official statistical operations included in the Andalusian Regional Government and has also been granted a favorable opinion by the Research Ethics Committee. The ESSOC is based on a Real-World Data design. It integrates observational data extracted from multiple sources including information based on surveys and clinical, epidemiological, population, and environmental registries. The surveys have an overlapping panel design with a total of over 22,000 effective interviews being carried out over three years from the beginning of the state of alarm in Spain. Their geographical scope is the Autonomous Region of Andalusia (8.4MM people, the fifth most populated region in Europe), and the population scopes are general population, population residing in disadvantaged areas, and population over the age of 55. The conceptual approach of this study encompasses all aspects affecting health that will contribute to an extraordinary increase in the current knowledge of the impact of the COVID-19 pandemic. Its results will be very useful for cross-disciplinary comparisons in population-based studies, and the methodology developed will serve as a model to be applied in other epidemiological studies.

Key messages

It is needed to provide specific, reliable, early, and timely data on the impact of COVID-19 that can be considered when making decisions to prepare and provide an effective Public Health response. Our research project integrates observational data extracted from multiple sources including information based on surveys and clinical, epidemiological, population, and environmental registries.

Characterization of SARS-CoV-2 RNA, Antibodies, and Neutralizing Capacity in Milk Produced by Women with COVID-19

Whether mother-to-infant SARS-CoV-2 transmission can occur during breastfeeding and, if so, whether the benefits of breastfeeding outweigh this risk during maternal COVID-19 illness remain important questions. Using RT-qPCR, we did not detect SARS-CoV-2 RNA in any milk sample (n = 37) collected from 18 women following COVID-19 diagnosis. Although we detected evidence of viral RNA on 8 out of 70 breast skin swabs, only one was considered a conclusive positive result. In contrast, 76% of the milk samples collected from women with COVID-19 contained SARS-CoV-2-specific IgA, and 80% had SARS-CoV-2-specific IgG. In addition, 62% of the milk samples were able to neutralize SARS-CoV-2 infectivity in vitro, whereas milk samples collected prior to the COVID-19 pandemic were unable to do so. Taken together, our data do not support mother-to-infant transmission of SARS-CoV-2 via milk. Importantly, milk produced by infected mothers is a beneficial source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.IMPORTANCE Results from prior studies assaying human milk for the presence of SARS-CoV-2, the causative virus of COVID-19, have suggested milk may act as a potential vehicle for mother-to-child transmission. Most previous studies are limited because they followed only a few participants, were cross-sectional, and/or failed to report how milk was collected and/or analyzed. As such, considerable uncertainty remains regarding whether human milk is capable of transmitting SARS-CoV-2 from mother to child. Here, we report that repeated milk samples collected from 18 women following COVID-19 diagnosis did not contain SARS-CoV-2 RNA; however, risk of transmission via breast skin should be further evaluated. Importantly, we found that milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness as milk likely provides specific immunologic benefits to infants.

Socioeconomic impact of restless legs syndrome and inadequate restless legs syndrome management across European settings

Restless legs syndrome (RLS) is one of the most common neurological disorders. It describes an irresistible urge to move the legs, mostly manifested in the evening and at night, which can lead to severe sleep disturbance. As part of the European Brain Council (EBC)-led Value-of-Treatment project, this study aimed at capturing the socioeconomic impact of RLS related to the inadequate diagnosis and treatment across different European healthcare settings. The economic burden of RLS was estimated using the published EBC framework of analysis in three separate European Union healthcare systems (France, Germany, and Italy). The RLS care pathway was mapped to identify the unmet needs of patients. Based on specific patient stories, the economic impact of correctly diagnosing RLS and changing between inadequate and target treatment was calculated using appropriate scenario analysis. RLS proved to be a significant personal and social burden, when epidemiological data, high prevalence of RLS, and its need for treatment are combined. By looking at the savings emerging from the provision of optimal care management (timely and correct diagnosis, evidence-based therapy, avoidance of therapy-related complications such as augmentation), the authors foresee substantial economic savings with the achievement of adequate diagnosis and treatment of RLS. Education about RLS is urgently needed for all subspecialties involved in RLS patient care as well as the general public. Equally important, the search for new causal treatment strategies should be intensified to reduce suffering and substantial societal cost.

COVID-19 and human milk: SARS-CoV-2, antibodies, and neutralizing capacity

Background

It is not known whether SARS-CoV-2 can be transmitted from mother to infant during breastfeeding, and if so whether the benefits of breastfeeding outweigh this risk. This study was designed to evaluate 1) if SARS-CoV-2 RNA can be detected in milk and on the breast of infected women, 2) concentrations of milk-borne anti-SARS-CoV-2 antibodies, and 3) the capacity of milk to neutralize SARS-CoV-2 infectivity.

Methods

We collected 37 milk samples and 70 breast swabs (before and after breast washing) from 18 women recently diagnosed with COVID-19. Samples were analyzed for SARS-CoV-2 RNA using RT-qPCR. Milk was also analyzed for IgA and IgG specific for the nucleocapsid protein, receptor binding domain (RBD), S2 subunit of the spike protein of SARS-CoV-2, as well as 2 seasonal coronaviruses using ELISA; and for its ability to neutralize SARS-CoV-2.

Results

We did not detect SARS-CoV-2 RNA in any milk sample. In contrast, SARS-CoV-2 RNA was detected on several breast swabs, although only one was considered conclusive. All milk contained SARS-CoV-2-specific IgA and IgG, and levels of anti-RBD IgA correlated with SARS-CoV-2 neutralization. Strong correlations between levels of IgA and IgG to SARS-CoV-2 and seasonal coronaviruses were noted.

Conclusions

Our data do not support maternal-to-child transmission of SARS-CoV-2 via milk; however, risk of transmission via breast skin should be further evaluated. Importantly, milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.

1122 Sleep Architecture and Leg Movement Activity During Sleep in Patients with Multiple Sclerosis

Introduction

Although sleep in patients with Multiple Sclerosis (MS) has been investigated in several studies using subjective measures, objective sleep data collected using polysomnography (PSG) are still scanty and often divergent. We herein present the largest study to date evaluating sleep architecture and total leg movement activity during sleep (LMS) in patients with MS.

Methods

We collected PSG recordings from 80 patients affected by multiple sclerosis (MS, 48.1±10.61yo 67.5% females), and 60 age and gender matched healthy control subjects (HC, 48.5±17.20 yo, 56% females). Group differences were computed using non-parametric statistics for all traditional sleep architecture parameters, LMS, short-interval (SILMS), periodic (PLMS), isolated LMS (ISOLMS) indices and duration, inter-movement interval (IMI) graphs and time-of-night distribution of LMS.

Results

Patients with MS showed a significantly decreased total sleep period, an increased number of awakenings and stages shifts per hour of sleep, and an increased representation of stage 1 (min and %) compared to the HC group; 26 (32.5%) MS patients had PLMS ≥15/hour versus 8 (13.3%) HC subjects. On average, the comparison between MS and HC groups yielded significant results in terms of an increase in LMS, PLMS, SILMS and ISOLMS indices but not durations. Moreover, MS patients displayed a higher periodicity index, an increased PLMS activity at all inter-movement intervals considered and their PLMS time-of-night distribution revealed that the PLMS increase was stable over the course of the night.

Conclusion

Sleep continuity is significantly impaired in patients with MS. Moreover, MS patients also an increased total LMS activity, including PLMS, which may contribute to disrupt sleep continuity. A disinhibition of lower spinal network due to cervical or supraspinal MS lesions might be implicated in the mechanisms underlying this latter finding.

Support

The Employer Department of Neurology, Regional Hospital Lugano (EOC), Lugano, Switzerland receives financial support from Teva, Merck Serono, Biogen Idec, Bayer Schering, Genzyme, Roche and Novartis. The submitted work is not related to these agreements.

0928 Heart Rate Variability During Sleep in Children and Adolescents with Restless Sleep Disorder or Restless Legs Syndrome and Normal Controls

Introduction

Restless sleep disorder (RSD) has been recently characterized clinically and polysomnographically in children and differentiated from restless legs syndrome (RLS). Heart rate variability (HRV) is a reliable method to quantify autonomic changes during sleep. The aim of this study was to characterize HRV in children with RSD, RLS and normal controls, with the hypothesis that children with RSD have a shift toward sympathetic predominance during sleep.

Methods

Polysomnographic recordings from thirty-two children who fulfilled RSD diagnostic criteria (19 boys and 13 girls), 32 children with RLS (20 boys and 12 girls) and 33 controls (17 boys and 16 girls) were included. Four ECG epochs were chosen, one for each stage, and were analyzed for automatic detection of R waves. Time domain and frequency domain HRV parameters were obtained and analyzed.

Results

Age and gender were not statistically different between groups. In terms of time domain only the standard deviation of the average RR interval during stage N3 was slightly but significantly higher in RSD than in RLS patients. In terms of frequency domains, the LF band and the LF/HF ratio were increased in RSD and the HF percentage was lower in RSD during sleep stages N3 and R. The LF band and the LF/HF ratio increased in RLS and the HF percentage was lower in RLS during stage W.

Conclusion

Children with RSD have increased sympathetic activation during sleep, particularly N3 and REM, compared to controls but, as expected, not during wakefulness. Differently, children with RLS have sympathetic activation during relaxed wakefulness preceding sleep and during sleep.

Support

Partial support by a grant of the Italian Ministry of Health RC n. 2751598 (R.F.)

0943 Increased Non-REM Sleep Instability in Children with Restless Sleep Disorder

Introduction

Restless sleep disorder (RSD) is a newly recognized condition characterized by motor movements involving large muscle groups with frequent repositioning or bed sheets disruption. We analyzed cyclic alternating pattern (CAP) in these children, a marker of sleep instability that might be associated with the motor episodes of RSD and may play a role in their daytime symptoms.

Methods

Polysomnographic recordings from thirty-eight children who fulfilled RSD diagnostic criteria (23 boys and 15 girls), 23 children with restless legs syndrome (RLS, 18 boys and 5 girls) and 19 controls (10 boys and 9 girls) were included. For CAP analysis, a previously developed, highly precise automated system, based on a deep learning recurrent neural network, was used.

Results

Age and gender were not statistically different between groups. RSD patients showed a lower percentage of A3 CAP subtypes than controls (median 9.8 vs. 18.2, p=0.0089), accompanied by shorter duration of the B phase of the CAP cycle (median 28.2 vs. 29.8 in controls, 30.2 in RLS, p=0.005) and shorter CAP cycle duration than both controls and RLS subjects (median 33.8 vs. 35.0 in controls, 35.8 in RLS, p=0.002). Finally, RSD children also showed a longer duration of CAP cycle sequences, when compared to controls (median 172.7 vs. 141.9, p=0.0063).

Conclusion

In conclusion, our study indicates that NREM sleep EEG shows an increased instability in RSD; these findings add to the current knowledge on the mechanisms of this newly recognized sleep disorder and suggest that sleep instability might be a favoring mechanism for the emergence of the motor episodes characterizing RSD.

Support

Partial support by a grant of the Italian Ministry of Health RC n. 2751598 (R.F.)

0934 Ambulatory Blood Pressure Monitoring During Overnight Polysomnography in Children and Adolescents

Introduction

During NREM sleep, sympathetic nervous system input decreases and systolic blood pressure drops. Sleep disorders can alter this mechanism. Ambulatory blood pressure monitors (ABPM) are increasingly used in children and are superior to clinic blood pressure in predicting cardiovascular morbidity and mortality. We aim to assess the effect of ABPM use during a sleep study in children and adolescents.

Methods

Subjects were children ages 7-18 from Seattle Children’s Hospital who underwent a sleep study for evaluation of suspected obstructive sleep apnea. Excluded children with known hypertension or taking a medication that altered blood pressure. An ABPM was placed on the right arm during the overnight sleep study and programmed to record BP every hour. Studies from children without OSA were analyzed for all sleep parameters. Data was compared with a control of children who underwent PSG and did not wear the ABPM. BP measurement was recorded and the PSG was reviewed for sleep stage, arousal, or awakening.

Results

To date, we have 15 children with ABPM age mean 11.6, SD 2.9 and 35 controls age mean 10.97 and SD 3.1, age, sex and BMI did not vary between groups. None of the PSG parameters was statistically different between groups including total sleep time, sleep efficiency, arousal index or sleep stage distribution. An average of 10 BP readings was obtained per patient. 53% of BP readings in N1 resulted in awakenings, compared to 39% in N2, 5% in N3 and 14.8% in REM. Systolic, diastolic, heart rate and mean arterial pressure showed appropriate dipping during sleep with appropriate circadian increase at 4 AM. Pulse pressure remained the same.

Conclusion

We have demonstrated the feasibility of using ABPM during PSG in children. Although sleep macroarchitecture did not show any significant difference in sleep efficiency or arousal index, further evaluation of each ABPM insufflation during the sleep study showed a sleep stage specific, sleep disruption with awakenings more likely to occur during N1 or N2 and less likely to occur during N3 or REM sleep. There was normal dipping and as expected circadian variability in the values.

Support

 

1001 Intravenous Ferric Carboxymaltose For Restless Legs Syndrome In Children And Adolescents

Introduction

Substantial scientific evidence implicates brain iron deficiency in the pathophysiology of restless legs syndrome (RLS). Current clinical guidelines recommend oral and intravenous iron (IV) in the treatment of both adult and pediatric RLS but studies using ferric carboxymaltose (FCM) are lacking in children and adolescents.

Methods

Retrospective case series of children and adolescents with RLS treated with IV FCM who had serum ferritin levels &lt;50 μg/L. Patients were offered a single dose of IV FCM, 15 mg/kg if weighting &lt;50 kg or 750 mg if weighting &gt;50 kg. Iron profile, serum ferritin, and severity assessment by the International Restless Legs Study Group severity scale (IRLS) were collected pre- and post-infusion. Clinical Global Impression Scale (CGI) was used instead of the IRLS for children. Phosphorus level and adverse effects were assessed post-infusion in all patients. Age and sex-matched children with RLS treated with oral iron supplementation (mean dosage 1.5±0.62 mg/kg/day) were included as a comparison group.

Results

Twenty-eight subjects (15 females, mean age 11.5 years, SD 4.23) and 24 controls were included. Baseline ferritin levels were not significantly different from those of controls but increased significantly from 13.9±7.02 to 112.9±12.00 μg/L after 8 weeks from infusion (p&lt;0.000001), when they were also significantly higher than control values (34.2±21.64 μg/mL, p&lt;0.000001). Transferrin saturation increased from 22.8±9.77% to 31.7±6.81% (p&lt;0.0001), total iron binding capacity decreased from 366.7±51.32 to 302.0±37.83 μg/dL (p&lt;0.0000035). RLS was reported to be resolved or improved in all children treated with IV iron (vs. 62.5% of controls) while none of them reported no change (vs. 37.5% of controls; Chi-square test 9.84, p&lt;0.002). IRLS Score decreased in adolescents from 30.7±22.68 to 3.2±4.21 (p&lt;0.000008) while CGI-I was “very much improved” in six children and “much improved” in four. Side effects were reported in 17.8% of patients treated IV and 20.8% controls (Chi-square 0.0169, p=0.897). FCM side effects included lightheadedness and gastrointestinal discomfort. Post IV phosphorus levels were normal in all participants.

Conclusion

This open-label, observational and retrospective study indicates that FCM IV infusion is an effective treatment for pediatric RLS with higher efficacy than oral iron supplementation.

Support

 

Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel

OBJECTIVE

Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians.

MATERIALS AND METHODS

A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags.

RESULTS

Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis.

CONCLUSIONS

This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.

Beyond the floor effect on the WISC-IV in individuals with Down syndrome: are there cognitive strengths and weaknesses?

BACKGROUND

Individuals with Down syndrome generally show a floor effect on Wechsler Scales that is manifested by flat profiles and with many or all of the weighted scores on the subtests equal to 1.

METHOD

The main aim of the present paper is to use the statistical Hessl method and the extended statistical method of Orsini, Pezzuti and Hulbert with a sample of individuals with Down syndrome (n = 128; 72 boys and 56 girls), to underline the variability of performance on Wechsler Intelligence Scale for Children-Fourth Edition subtests and indices, highlighting any strengths and weaknesses of this population that otherwise appear to be flattened.

RESULTS

Based on results using traditional transformation of raw scores into weighted scores, a very high percentage of subtests with weighted score of 1 occurred in the Down syndrome sample, with a floor effect and without any statistically significant difference between four core Wechsler Intelligence Scale for Children-Fourth Edition indices. The results, using traditional transformation, confirm a deep cognitive impairment of those with Down syndrome. Conversely, using the new statistical method, it is immediately apparent that the variability of the scores, both on subtests and indices, is wider with respect to the traditional method.

CONCLUSION

Children with Down syndrome show a greater ability in the Verbal Comprehension Index than in the Working Memory Index.

REM sleep behavior disorder and periodic leg movements during sleep in ALS

OBJECTIVE

To assess sleep characteristics and the occurrence of abnormal muscle activity during sleep, such as REM sleep without atonia (RSWA), REM sleep behavior disorder (RBD), and periodic leg movements during sleep (PLMS), in patients with amyotrophic lateral sclerosis (ALS).

METHODS

A total of 41 patients with ALS and 26 healthy subjects were submitted to clinical interview and overnight video-polysomnography.

RESULTS

A total of 22 patients with ALS (53.6%) reported poor sleep quality. Polysomnographic studies showed that patients with ALS had reduced total sleep time, increased wakefulness after sleep onset, shortened REM and slow-wave sleep, and decreased sleep efficiency, compared to controls. Polysomnographic abnormalities were not different in patients reporting good or poor sleep and were not correlated to clinical and demographic variables. The PLMS index was significantly higher in patients with ALS than in healthy subjects, and 22 patients (53.6%) showed a PLMS index > 15/h, vs 4 (15.4%) controls (P < 0.001). Finally, two patients with ALS (4.9%) had RBD, and two more patients presented RSWA (4.9%), whereas no controls showed abnormalities of REM sleep.

CONCLUSION

Patients with ALS frequently present abnormalities of sleep that can be documented both at the clinical interview and at the polysomnographic evaluation, including insomnia, fragmented sleep, and increased PLMS. Moreover, abnormalities of REM sleep can be found in some of these patients.

Brain Morphometry and Psychobehavioural Measures in Autistic Low-Functioning Subjects

In the last two decades neurological research has significantly increased knowledge on the neuroanatomic bases of autism. Several autopsy and quantitative magnetic resonance imaging (MRI) studies have reported central nervous system (CNS) abnormalities which may underlie the social, language and cognitive dysfunction typical of the autistic disorder.

Despite the wealth of evidence that the “autistic brain” is different from normal in a number of structures, the relationship between the severity of the developmental impairment in autism and the degree of the brain abnormality remains unknown.

The aim of the present study is to correlate the areas of some brain regions, as calculated on the basis of MRI morphometry, with the Childhood Autism Rating Scale (CARS) and with the Psychoeducational Profile Revised (PEP-R) scores in a group of 22 autistic mentally retarded male subjects.

Recommendations of the Sleep Study Group of the Italian Dementia Research Association (SINDem) on clinical assessment and management of sleep disorders in individuals with mild cognitive impairment and dementia: a clinical review

Clinical assessment and management of sleep disturbances in patients with mild cognitive impairment and dementia has important clinical and social implications. Poor sleep results in an increased risk of morbidities and mortality in demented patients and is a source of stress for caregivers. Sleep disturbances show high prevalence in mild cognitive impairment and dementia patients and they are often associated one to another in the same patient. A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of individuals with cognitive decline. The Sleep Study Group of the Italian Dementia Research Association (SINDem) reviewed evidence from original research articles, meta-analyses and systematic reviews published up to December 2013. The evidence was classified in quality levels (I, II, III) and strength of recommendations (A, B, C, D, E). Where there was a lack of evidence, but clear consensus, good practice points were provided. These recommendations may not be appropriate for all circumstances and should therefore be adopted only after a patient's individual characteristics have been carefully evaluated.