Pediatric Headache and Epilepsy Comorbidity in the Pragmatic Clinical Setting.

INTRODUCTION: Demographic and clinical data were collected from three cross-sectional samples, from the headache and epilepsy clinics according to respective protocols. During structured interviews, we examined the co-occurrence of headaches and epilepsy in children and their families: (1) 172 children from the headache clinic, were questioned for the number and type of epileptic seizures and epilepsy diagnosis. (2) Around 70 children from the epilepsy clinic for the frequency and type of headaches and headache syndrome diagnosis. (3) A total of 149 parents of children with benign childhood epilepsy with centro-temporal spikes (BCECTS) and childhood absence epilepsy (CAE), for the relative frequency of headaches in first- and second-degree relatives. RESULTS: Out of 172, 84 (48.8%) children with headache had a migraine and 60 (34.9%) had tension headaches; 3 children (1.7%) had epilepsy or unprovoked seizures. Migraine and epilepsy, co-occurred in 2/84 (2.3%). Eight out of 70 patients with epilepsy had headaches (11.4%); none had migraine. Around 43% of patients with BCECTS or CAE had a family history of headache, more prevalent in first-degree relatives of children with BCECTS than CAE. CONCLUSION: Contrary to existing literature, migraine and epilepsy, co-occurred infrequently in these highly selected samples. Family history of headache was frequent in patients with BCECTS and CAE, without any significant difference between the two.

Sleep apnoea syndrome and early stage cirrhosis: a pilot study.

OBJECTIVES: Hepatic encephalopathy in patients with end-stage liver cirrhosis is associated with alterations in sleep patterns. Cirrhosis may also affect pulmonary function and it might be involved in the development of obstructive sleep apnoea syndrome (OSAS) in patients with ascites. We carried out a study to evaluate the presence of OSAS in cirrhotic patients without evidence of ascites (early stage cirrhosis). METHODS: We investigated 20 patients with Child A or B cirrhosis (19 and one, respectively) and 10 non-cirrhotic patients with chronic viral hepatitis (disease control group). All subjects were interviewed and underwent a thorough physical examination, a full polysomnographic study and a pulmonary function testing by spirometry. Serum samples were also obtained in order to determine the liver function tests. RESULTS: The presence of OSAS and inverted sleep patterns was similar in cirrhotic patients and disease controls. However, significant correlations were revealed between age and hypopnoeas per hour of sleep; age and the Apneas/Hypopneas Index (AHI); age and FEV1/FVC; gamma-glutamyl transpeptidase and FEV1/FVC; and total bilirubin and total sleep time. CONCLUSIONS: Early stage cirrhosis is not associated with sleep disorders and OSAS. However, total bilirubin levels might be a useful laboratory marker for early assessment of disturbance in sleep patterns and therefore of subclinical hepatic encephalopathy in Child A cirrhosis.

Safety of botulinum toxin A in children and adolescents with cerebral palsy in a pragmatic setting.

This retrospective study aimed to examine the safety of botulinum toxin A (BoNT-A) treatment in a paediatric multidisciplinary cerebral palsy clinic. In a sample of 454 patients who had 1515 BoNT-A sessions, data on adverse events were available in 356 patients and 1382 sessions; 51 non-fatal adverse events were reported (3.3% of the total injections number, 8.7% of the patients). On five occasions, the adverse reactions observed in GMFCS V children were attributed to the sedation used (rectal midazolam plus pethidine; buccal midazolam) and resulted in prolongation of hospitalization. Of the reactions attributed to the toxin, 23 involved an excessive reduction of the muscle tone either of the injected limb(s) or generalized; others included local pain, restlessness, lethargy with pallor, disturbance in swallowing and speech production, seizures, strabismus, excessive sweating, constipation, vomiting, a flu-like syndrome and emerging hypertonus in adjacent muscles. Their incidence was associated with GMFCS level and with the presence of epilepsy (Odds ratio (OR) = 2.74 - p = 0.016 and OR = 2.35 - p = 0.046, respectively) but not with BoNT-A dose (either total or per kilogram). In conclusion, treatment with BoNT-A was safe; adverse reactions were mostly mild even for severely affected patients. Their appearance did not necessitate major changes in our practice.

Botulinum toxin treatment in upper limb spasticity: treatment consistency.

This study assessed treatment consistency of botulinum toxin administration in spastic upper limbs under pragmatic conditions, as derived through stability of dosages and between injections intervals. Over a period of 8 years, 153 children (81 with bilateral spastic cerebral palsy, 72 with unilateral) were treated according to accepted, experience-based guidelines with Botox and Dysport. Treatment response was based on assessment of spasticity and attainment of pre-determined goals at 3, 6 and 12 months post each treatment. Mean age at treatment onset was 6y 4mo (SD: 4y 10mo), median F/U, 2.5 years (4 months-6 8/12 years). Number of injection sessions was 1-10; few had more than 6 sessions. In 106 (69.28%) children, more than one anatomic regions of the limb were injected. Most (56.2%), had at least two injection sessions; median time interval between the sessions was 9 months (IQR: 4-35 months, similar for unilateral and bilateral cerebral palsy, p = 0.874). Children >4 years old at the first treatment had longer intervals between sessions (25.8%) compared to younger ones (p = 0.010). The mixed effects models demonstrated that botulinum toxin dosage was stable over subsequent visits (p = 0.144) and that intermediate intervals for subsequent visits were similar to the first one (p = 0.279).

Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas.

PURPOSE: The aim of our study was to investigate the roles of cerebral perfusion pressure (CPP) and microdialysis marker values on the clinical outcome of patients with spontaneous intracerebral hematoma. MATERIALS AND METHODS: Twenty-seven patients (18 men; mean ± SD age, 54.17 ± 10.05 years; 9 women, mean ± SD age, 65.00 ± 4.24 years) with a GCS of 8 or less upon admission were included in this study. After a 6-month follow-up period, a linear regression model was applied to evaluate the outcomes using the Glasgow Outcome Scale (GOS). RESULTS: Of the 27 patients, 16 died within the first 6 months after discharge from the hospital. Six patients had a favorable prognosis after 6 months. In the patients who had a favorable outcome (GOS = 4 or GOS = 5), the CPP was above 75.46 mm Hg, and intracranial pressure was below 14.21 mm Hg. No patient with a favorable prognosis had a lactate-pyruvate (L/P) ratio greater than 37.40. An inverse linear relationship was found among the L/P ratio, the CPP, and patient outcome. CONCLUSION: The L/P ratio and CPP were found to be related to patient outcome. In addition, a CPP greater than 75.46 mm Hg and an L/P ratio lower than 37.40 mm Hg were related to a favorable outcome.

The effect of a psycho-educational program on CARS scores and short sensory profile in autistic children.

UNLABELLED: There is great demand for effective management of children with Autistic Spectrum Disorders (ASD). This study aimed to investigate the effect of an individually tailored psycho-educational program for autistic children on the scores of the Childhood Autism Rating Scale (CARS) and the Short Sensory Profile (SSP). METHODS: Forty children (36 males) were enrolled into an intervention program which consisted of occupational therapy including sensory integration techniques, speech therapy, social skills therapy and parent-directed approaches. Autism severity was assessed using CARS; sensory response capability with the SSP pre- and post-treatment. RESULTS: Eight children were intellectually normal; 12 borderline and 20 of low intelligence. Pre-treatment CARS showed that 8 were mildly autistic, 32 moderately-severely autistic. Post-treatment, 24 children changed category; 11 were no longer autistic. The percentage of children performing in the definitive difference region, according to total SSP score, changed slightly (45% vs 32.5%). Comparison of the pre- and post-treatment values revealed that CARS decreased significantly (p < 0.001), whereas total SSP did not (p = 0.294). Tactile sensitivity and low energy/weakness sections, though, were significantly different pre- and post-treatment. Longitudinal analysis, taking into account other confounding factors besides time, further revealed a significant decrement for CARS score with time but not for SSP score (p < 0.001 and p = 0.288, respectively). Similarly, intelligence levels affected CARS but not SSP values (p < 0.001 and p = 0.813, respectively). CONCLUSION: Individually tailored psycho-educational therapy had a significant effect on autism severity according to CARS. Changes in the SSP scores were not significant.

Effects of psycho-educational training and stimulant medication on visual perceptual skills in children with attention deficit hyperactivity disorder.

UNLABELLED: Attention deficit hyperactivity disorder (ADHD) is treated with stimulants and psycho-educational remedial programs despite limited literature support for the latter. This study aimed to examine changes in a "Test of Visual Perceptual Skills" (TVPS) that has not been previously reported in children with ADHD enrolled in such a program. METHODS: Sixteen children, 7-11 years old, with ADHD were involved in occupational therapy and special education geared towards attention training. Six months later methylphenidate 1 mg/kg/day was prescribed. It was not taken by eight children because of family choice. The TVPS was given twice, upon diagnosis, and 8 months post-intervention. The groups were compared by a repeated measures analysis of variance (ANOVA) with medication as a between groups factor and test-retest scores as within factor. RESULTS: All children demonstrated increases in total scores in the second measurement. Medicated children scored higher but ANOVA showed a nonsignificant F for the two groups, medicated and unmedicated (F = 0.0031, p = 0.9563), indicating a nondifferential effect of the two levels of treatment. It revealed a significant F for the pre- and post-treatment total TVPS scores (F = 30.91, p < 0.0001) indicating a significant difference between pre- and post-treatment tests. The interaction between pre-post treatment and level of treatment (medicated-unmedicated) was nonsignificant (F = 2.20, p = 0.1604). CONCLUSION: TVPS scores improved in all children following intervention. Medicated children did better, but differences were nonsignificant.