[Withdrawal and reintroduction of pharmacological treatment of epilepsy in paediatric patients. Our experience]. / Retirada y reintroducción del tratamiento farmacológico de la epilepsia en pacientes pediátricos. Nuestra experiencia.

INTRODUCTION: There are many variables to be considered in the withdrawal of treatment for epileptic seizures, which requires a risk-benefit assessment. PATIENTS AND METHODS: A retrospective study of patients in a neuropaediatric practice who required the reintroduction of treatment for epilepsy after its initial withdrawal, and who continue to receive anti-seizure drugs. RESULTS: Twenty-three of 57 children whose treatment was withdrawn are currently being administered the treatment as a monotherapy. Attempts at withdrawal were made with 17 patients, with a mean seizure-free period of 26 months; range: 8-47 months (excluding one patient who never stopped presenting seizures). Mean age at the time of the last known data: 16 years; range: 7-28 years. Average time until the first seizure after withdrawal: 12 months; range: 1-82 months. Seizures persist despite the current treatment administered in eight cases. Two or three attempts to withdraw treatment were made in six patients, with a mean seizure-free period of 28.6 months; range: 22-48 months. Mean age at the time of the last known data: 18.68 years; range: 13-37 years. Average time until the first seizure after withdrawal: 8.2 months; range: 1-30 months. They presented seizures after treatment four was reintroduced. 52% of the patients presented seizures while receiving the drug, which was discontinued. The treatment was withdrawn in cases meeting criteria for persistent seizures: three refractory epilepsies, five symptomatic focal epilepsies, four cases with intellectual disability, five adolescent-onset epilepsies, and failures in previous withdrawal in 23 cases and 30 attempts. CONCLUSION: The decision to withdraw treatment must be personalised, and consider the risk of relapse, taking into account efficacy and tolerability, and behaviour and neurodevelopment in particular.

TITLE: Retirada y reintroducción del tratamiento farmacológico de la epilepsia en pacientes pediátricos. Nuestra experiencia.Introducción. Existen muchas variables que se deben considerar en la retirada del tratamiento anticrisis epilépticas, que precisa una evaluación riesgo-beneficio. Pacientes y métodos. Estudio retrospectivo en pacientes de una consulta de neuropediatría que precisaron reintroducir el tratamiento de la epilepsia tras su retirada inicial y continúan con fármacos anticrisis epilépticas. Resultados. De 57 niños a quienes se les retiró el tratamiento, 23 lo llevan actualmente, todos en monoterapia. En 17 se realizó un intento de retirada, con tiempo medio previo sin crisis de 26 meses; rango: 8-47 meses (excluido uno que nunca dejó de presentarlas). Edad media en el momento de los últimos datos conocidos: 16 años; rango: 7-28 años. Tiempo medio hasta nueva crisis tras retirada: 12 meses; rango: 1-82 meses. En ocho casos persisten crisis pese al tratamiento actual. En seis se realizaron 2-3 intentos, con un tiempo medio previo sin crisis de 28,6 meses; rango: 22-48 meses. Edad media en el momento de los últimos datos conocidos: 18,68 años; rango: 13-37 años. Tiempo medio hasta nueva crisis tras retirada: 8,2 meses; rango: 1-30 meses. Presentaron crisis una vez reintroducido el tratamiento cuatro. Había presentado crisis recibiendo el fármaco que se suspendió, el 52%. Se retiró el tratamiento a casos con criterios de persistencia de crisis: tres epilepsias refractarias, cinco focales sintomáticas, cuatro con discapacidad intelectual, cinco epilepsias de inicio en la adolescencia, y en 23 casos y 30 intentos fallidos en la retirada previa. Conclusión. La decisión de retirada debe ser individualizada, conociendo el riesgo de recaída, atendiendo a la eficacia y la tolerabilidad, especialmente el comportamiento y el neurodesarrollo.

Radiative relaxation in isolated large carbon clusters: Vibrational emission versus recurrent fluorescence.

Recurrent fluorescence (RF) from isolated carbon clusters containing between 24 and 60 atoms is theoretically investigated as a function of internal energy, cluster size, and structural features. The vibrational relaxation kinetics and the associated IR emission spectra are determined by means of a Monte Carlo approach with vibrational density of states computed in the harmonic approximation. RF is generally found to be highly competitive with vibrational emission. The behaviors predicted for clusters of various sizes and archetypal structures indicate that the IR emission spectra are strongly influenced by RF, an energy gap law being obtained for the evolution of the RF rate constant depending on the electronic excitation state. The present results are relevant to the photophysics of the interstellar medium and could contribute to elucidating the carriers of the extended red emission bands and the continuum emission lying below the aromatic infrared bands believed to originate from mixed aromatic-aliphatic compounds.

Functional activation of the periaqueductal gray matter during conditioned and unconditioned fear in guinea pigs confronted with the Boa constrictor constrictor snake.

The periaqueductal gray matter (PAG) is an essential structure involved in the elaboration of defensive responses, such as when facing predators and conspecific aggressors. Using a prey vs predator paradigm, we aimed to evaluate the PAG activation pattern evoked by unconditioned and conditioned fear situations. Adult male guinea pigs were confronted either by a Boa constrictor constrictor wild snake or by the aversive experimental context. After the behavioral test, the rodents were euthanized and the brain prepared for immunohistochemistry for Fos protein identification in different PAG columns. Although Fos-protein-labeled neurons were found in different PAG columns after both unconditioned and conditioned fear situations at the caudal level of the PAG, we found greater activation of the lateral column compared to the ventrolateral and dorsomedial columns after predator exposure. Moreover, the lateral column of the PAG showed higher Fos-labeled cells at the caudal level compared to the same area at the rostral level. The present results suggested that there are different activation patterns of PAG columns during unconditioned and conditioned fear in guinea pigs. It is possible to hypothesize that the recruitment of specific PAG columns depended on the nature of the threatening stimulus.

Functional activation of the periaqueductal gray matter during conditioned and unconditioned fear in guinea pigs confronted with the Boa constrictor constrictor snake

The periaqueductal gray matter (PAG) is an essential structure involved in the elaboration of defensive responses, such as when facing predators and conspecific aggressors. Using a prey vs predator paradigm, we aimed to evaluate the PAG activation pattern evoked by unconditioned and conditioned fear situations. Adult male guinea pigs were confronted either by a Boa constrictor constrictor wild snake or by the aversive experimental context. After the behavioral test, the rodents were euthanized and the brain prepared for immunohistochemistry for Fos protein identification in different PAG columns. Although Fos-protein-labeled neurons were found in different PAG columns after both unconditioned and conditioned fear situations at the caudal level of the PAG, we found greater activation of the lateral column compared to the ventrolateral and dorsomedial columns after predator exposure. Moreover, the lateral column of the PAG showed higher Fos-labeled cells at the caudal level compared to the same area at the rostral level. The present results suggested that there are different activation patterns of PAG columns during unconditioned and conditioned fear in guinea pigs. It is possible to hypothesize that the recruitment of specific PAG columns depended on the nature of the threatening stimulus.

Prevalence of nodal involvement in rectal cancer after chemoradiotherapy.

BACKGROUND: The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data. METHODS: Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS). RESULTS: Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death. CONCLUSION: Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.

When patients are diagnosed with rectal cancer and the tumour grows beyond the rectal wall there is a high risk that the tumour has spread to nearby lymph nodes. This study showed that this relationship between tumour invasion depth and lymph node involvement is similar after treatment with (chemo)radiotherapy. Patients who have tumour cells remaining in the lymph nodes after (chemo) radiotherapy have a worse prognosis than patients who do not have cancer cells remaining in the lymph nodes. When an organ-preserving treatment is considered as an alternative therapy, this should be kept in mind during patient counselling.

Intraoperative electron beam radiotherapy and perioperative high-dose-rate brachytherapy in previously irradiated oligorecurrent gynecological cancer: clinical outcome analysis.

BACKGROUND: Pelvic recurrences from previously irradiated gynecological cancer lack solid evidence for recommendation on salvage. METHODS: A total of 58 patients were included in this clinical analysis. Salvage surgery was performed for locoregional relapse within previously irradiated pelvic area after initial surgery and adjuvant radiotherapy or radical external beam radiotherapy. The primary tumor diagnosis included cervical cancer (n = 47, 81%), uterine cancer (n = 4, 7%), and other types (n = 7, 12%). Thirty-three patients received adjuvant IOERT (1984-2000) at a median dose of 15 Gy (range 10-20 Gy) and 25 patients received adjuvant PHDRB (2001-2016) at a median dose of 32 Gy (range 24-40 Gy) in 6, 8, or 10 b.i.d. fractions. RESULTS: The median follow-up was 5.6 years (range 0.5-14.2 years). Twenty-nine (50.0%) patients had positive surgical margins. Grade ≥ 3 toxic events were recorded in 34 (58.6%) patients. The local control rate at 2 years was 51% and remained stable up to 14 years. Disease-free survival rates at 2, 5, and 10 years were 17.2, 15.5, and 15.5%, respectively. Overall survival rates at 2, 5, and 10 years were 58.1, 17.8, and 17.8%, respectively. CONCLUSIONS: IOERT and PHDRB account for an effective salvage in oligorecurrent gynecological tumors. Patients with previous pelvic radiation suitable for salvage surgery and at risk of inadequate margins could benefit from adjuvant reirradiation in form of IOERT or PHDRB. However, the rate of severe grade ≥ 3 toxicity associated with the entire treatment program is relevant and needs to be closely counterbalanced against the expected therapeutic gain.

Solvation of coronene oligomers by para-H2 molecules: the effects of size and shape.

The stepwise solvation of various cationic coronene oligomers by para-hydrogen (p-H2) molecules was computationally investigated using a united-atom model for the p-H2 molecules and the Silvera-Goldman potential, together with a polarizable description for the interaction with the hydrocarbon molecules. A survey of the energy landscape for oligomers containing between 1 and 4 coronene molecules and possible different conformers was carried out using standard global optimization, the hydrocarbon complex being kept as rigid. The most stable structures provided the starting configuration of systematic path-integral molecular dynamics simulations at 2 K. The variations of the geometric and energetic properties of the solvation shell were determined with increasing number of para-hydrogen molecules. The relative stability of the solvation shell is generally found to be more robustly determined by the energy increment (or dissociation energy) than by geometrical indicators, especially when the oligomers have less ordered structures. In agreement with recent mass spectrometry experiments, the size at which the first solvation shell is complete is found to vary approximately linearly with the oligomer size when the coronene molecules stack together, with a slope that is related to the offset between two successive molecules.

JSCO-ESMO-ASCO-JSMO-TOS: international expert consensus recommendations for tumour-agnostic treatments in patients with solid tumours with microsatellite instability or NTRK fusions.

A Japan Society of Clinical Oncology (JSCO)-hosted expert meeting was held in Japan on 27 October 2019, which comprised experts from the JSCO, the Japanese Society of Medical Oncology (JSMO), the European Society for Medical Oncology (ESMO), the American Society of Clinical Oncology (ASCO), and the Taiwan Oncology Society (TOS). The purpose of the meeting was to focus on what we have learnt from both microsatellite instability (MSI)/deficient mismatch repair (dMMR) biomarkers in predicting the efficacy of anti-programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) immunotherapy, and the neurotrophic tyrosine receptor kinase (NTRK) gene fusions in predicting the efficacy of inhibitors of the tropomyosin receptor kinase (TRK) proteins across a range of solid tumour types. The recent regulatory approvals of the anti-PD-1 antibody pembrolizumab and the TRK inhibitors larotrectinib and entrectinib, based on specific tumour biomarkers rather than specific tumour type, have heralded a paradigm shift in cancer treatment approaches. The purpose of the meeting was to develop international expert consensus recommendations on the use of such tumour-agnostic treatments in patients with solid tumours. The aim was to generate a reference document for clinical practice, for pharmaceutical companies in the design of clinical trials, for ethics committees in the approval of clinical trial protocols and for regulatory authorities in relation to drug approvals, with a particular emphasis on diagnostic testing and patient selection.

Coarse-grained modeling of the nucleation of polycyclic aromatic hydrocarbons into soot precursors.

The aggregation and physical growth of polycyclic aromatic hydrocarbon (PAH) molecules was simulated using a coarse-grained (CG) approach based on the Paramonov-Yaliraki (PY) potential and a stochastic Monte Carlo framework, following earlier efforts in which the structure [Phys. Chem. Chem. Phys., 2016, 18, 13736] and equilibrium thermodynamics [Phys. Chem. Chem. Phys., 2017, 19, 1884] were investigated and critically compared to the predictions of all-atom models. Homomolecular and heteromolecular assemblies of pyrene, coronene, and circumcoronene were considered at various temperatures and compositions, and the distributions of aggregation products were characterized. Under the simulated conditions, and in agreement with earlier studies, the clusters are rather small and, in the case of pyrene-rich systems, only formed below 1000 K. The clusters obtained by spontaneous aggregation of isolated molecules are statistically analysed. For the selected sizes of tetramers and octamers, broad distributions of isomers are obtained with a clear entropic stabilization. In heteronuclear assemblies, our results suggest a minor spontaneous segregation towards pure and equi concentrations at variance with purely statistical expectations.

Quantum Chemical View on the Growth Mechanisms of Odd-Sized Nitrogen Cluster Anions.

The stable structures of odd-numbered anionic nitrogen clusters, N2 n+3-, have been theoretically investigated in the size range n = 1-9 using a variety of quantum chemistry methods that include perturbation theory, coupled cluster, and density-functional theory with different exchange-correlation functionals. We generally find that the clusters are composed of an azide chromophore N3- surrounded by essentially neutral nitrogen molecules. The growth initially proceeds by placing the neutral molecules parallel to the azide anion, completing a first shell at N13-, above which the extra molecules arrange on the side but with a significantly lower binding energy. Comparison with the cyclic N5- anionic core shows that the latter is unfavorable, the spectral signatures of both N5- and N2N3- being provided in both the infrared and ultraviolet ranges. The trend of these clusters to be highly stable as (N2) nN3- agrees with recent mass spectrometry experiments under the cryogenic environment of helium droplets. The issues associated with the successful development of a nonreactive force field for such clusters are also highlighted.

Atomistic modeling of the infrared response of fullerenes under hydrostatic pressure.

The anharmonic infrared spectrum of individual C60 and C70 fullerenes under hydrostatic pressure was theoretically computed by means of atomistic simulations. Using a tight-binding model for the fullerenes and a simple particle-based pressure-transmitting fluid, the structural and vibrational properties were determined at room temperature and up to 20 GPa. All properties generally exhibit relative variations that are linear with increasing pressure, but whose magnitude can be comparable to pure thermal effects. The bond length contraction usually agrees with existing results, and for C70 our approach manages to reproduce the occasionally negative pressure coefficient found for some low-frequency modes in experiments.

Maxwell-Boltzmann versus non-ergodic events in the velocity distribution of water molecules evaporated from protonated water nanodroplets.

Measurement of velocity distributions of evaporated water monomers from small mass- and energy-selected protonated water clusters allows probing the extent of thermalization after excitation of these ultimately small nanodroplets. Electronic excitation of a molecule in the cluster is here induced by a single collision with an argon atom in the keV energy range. The measured velocity distributions of the departing neutral molecules exhibit bimodal shapes with a lower-velocity part consistent with a complete redistribution of the deposited energy in the entire cluster and a higher-velocity contribution corresponding to evaporation before complete energy redistribution. Statistical molecular dynamics calculations reproduce the bimodal shape of the velocity distributions by assuming an initial spreading of the excitation energy among all modes, thereby reproducing the lower velocity contribution of the distribution. By contrast, assuming the deposited energy to be initially localized among the modes of a single molecule leads to calculated distributions with two components whose shape is in accordance with the experimental results. The characteristics and the relative abundance of these two contributions in the velocity distributions obtained are presented and discussed as a function of the number of molecules (n = 2-10) in the ionized nanodroplet H+(H2O) n .

Sequential evaporation of water molecules from protonated water clusters: measurement of the velocity distributions of the evaporated molecules and statistical analysis.

Velocity distributions of neutral water molecules evaporated after collision induced dissociation of protonated water clusters H+(H2O)n≤10 were measured using the combined correlated ion and neutral fragment time-of-flight (COINTOF) and velocity map imaging (VMI) techniques. As observed previously, all measured velocity distributions exhibit two contributions, with a low velocity part identified by statistical molecular dynamics (SMD) simulations as events obeying the Maxwell-Boltzmann statistics and a high velocity contribution corresponding to non-ergodic events in which energy redistribution is incomplete. In contrast to earlier studies, where the evaporation of a single molecule was probed, the present study is concerned with events involving the evaporation of up to five water molecules. In particular, we discuss here in detail the cases of two and three evaporated molecules. Evaporation of several water molecules after CID can be interpreted in general as a sequential evaporation process. In addition to the SMD calculations, a Monte Carlo (MC) based simulation was developed allowing the reconstruction of the velocity distribution produced by the evaporation of m molecules from H+(H2O)n≤10 cluster ions using the measured velocity distributions for singly evaporated molecules as the input. The observed broadening of the low-velocity part of the distributions for the evaporation of two and three molecules as compared to the width for the evaporation of a single molecule results from the cumulative recoil velocity of the successive ion residues as well as the intrinsically broader distributions for decreasingly smaller parent clusters. Further MC simulations were carried out assuming that a certain proportion of non-ergodic events is responsible for the first evaporation in such a sequential evaporation series, thereby allowing to model the entire velocity distribution.

Temperature- and field-induced structural transitions in magnetic colloidal clusters.

Magnetic colloidal clusters can form chain, ring, and more compact structures depending on their size. In the present investigation we examine the combined effects of temperature and external magnetic field on these configurations by means of extensive Monte Carlo simulations and a dedicated analysis based on inherent structures. Various thermodynamical, geometric, and magnetic properties are calculated and altogether provide evidence for possibly multiple structural transitions at low external magnetic field. Temperature effects are found to overcome the ordering effect of the external field, the melted stated being associated with low magnetization and a greater compactness. Tentative phase diagrams are proposed for selected sizes.

The quantum structure of anionic hydrogen clusters.

A flexible and polarizable interatomic potential has been developed to model hydrogen clusters interacting with one hydrogen anion, (H2)nH-, in a broad range of sizes n = 1-54 and parametrized against coupled cluster quantum chemical calculations. Using path-integral molecular dynamics simulations at 1 K initiated from the putative classical global minima, the equilibrium structures are found to generally rely on icosahedral shells with the hydrogen molecules pointing toward the anion, producing geometric magic numbers at sizes n = 12, 32, and 44 that are in agreement with recent mass spectrometry measurements. The energetic stability of the clusters is also connected with the extent of vibrational delocalization, measured here by the fluctuations among inherent structures hidden in the vibrational wave function. As the clusters grow, the outer molecules become increasingly free to rotate, and strong finite size effects are also found between magic numbers, associated with more prominent vibrational delocalization. The effective icosahedral structure of the 44-molecule cluster is found to originate from quantum nuclear effects as well, the classical structure showing no particular symmetry.