Pathological laughter and crying: insights from lesion network-symptom-mapping.

The study of pathological laughter and crying (PLC) allows insights into the neural basis of laughter and crying, two hallmarks of human nature. PLC is defined by brief, intense and frequent episodes of uncontrollable laughter or crying provoked by trivial stimuli. It occurs secondary to CNS disorders such as stroke, tumours or neurodegenerative diseases. Based on case studies reporting various lesions locations, PLC has been conceptualized as dysfunction in a cortico-limbic-subcortico-thalamo-ponto-cerebellar network. To test whether the heterogeneous lesion locations are indeed linked in a common network, we applied 'lesion network-symptom-mapping' to 70 focal lesions identified in a systematic literature search for case reports of PLC. In lesion network-symptom-mapping normative connectome data (resting state functional MRI, n = 100) is used to identify the brain regions that are likely affected by diaschisis based on the lesion locations. With lesion network-symptom-mapping we were able to identify a common network specific for PLC when compared with a control cohort (n = 270). This bilateral network is characterized by positive connectivity to the cingulate and temporomesial cortices, striatum, hypothalamus, mesencephalon and pons, and negative connectivity to the primary motor and sensory cortices. In the most influential pathophysiological model of PLC, a centre for the control and coordination of facial expressions, respiration and vocalization in the periaqueductal grey is assumed, which is controlled via two pathways: an emotional system that exerts excitatory control of the periaqueductal grey descending from the temporal and frontal lobes, basal ganglia and hypothalamus; and a volitional system descending from the lateral premotor cortices that can suppress laughter or crying. To test whether the positive and negative PLC subnetworks identified in our analyses can indeed be related to an emotional system and a volitional system, we identified lesions causing emotional (n = 15) or volitional facial paresis (n = 46) in a second literature search. Patients with emotional facial paresis show preserved volitional movements but cannot trigger emotional movements in the affected hemiface, while the reverse is true for volitional facial paresis. Importantly, these lesions map differentially onto the PLC subnetworks: the 'positive PLC subnetwork' is part of the emotional system and the 'negative PLC subnetwork' overlaps with the volitional system for the control of facial movements. Based on this network analysis we propose a two-hit model of PLC: a combination of direct lesion and indirect diaschisis effects cause PLC through the loss of inhibitory cortical control of a dysfunctional emotional system.

Early screening of autism spectrum disorder using cry features.

The increase in the number of children with autism and the importance of early autism intervention has prompted researchers to perform automatic and early autism screening. Consequently, in the present paper, a cry-based screening approach for children with Autism Spectrum Disorder (ASD) is introduced which would provide both early and automatic screening. During the study, we realized that ASD specific features are not necessarily observable in all children with ASD and in all instances collected from each child. Therefore, we proposed a new classification approach to be able to determine such features and their corresponding instances. To test the proposed approach a set of data relating to children between 18 to 53 months which had been recorded using high-quality voice recording devices and typical smartphones at various locations such as homes and daycares was studied. Then, after preprocessing, the approach was used to train a classifier, using data for 10 boys with ASD and 10 Typically Developed (TD) boys. The trained classifier was tested on the data of 14 boys and 7 girls with ASD and 14 TD boys and 7 TD girls. The sensitivity, specificity, and precision of the proposed approach for boys were 85.71%, 100%, and 92.85%, respectively. These measures were 71.42%, 100%, and 85.71% for girls, respectively. It was shown that the proposed approach outperforms the common classification methods. Furthermore, it demonstrated better results than the studies which used voice features for screening ASD. To pilot the practicality of the proposed approach for early autism screening, the trained classifier was tested on 57 participants between 10 to 18 months. These 57 participants consisted of 28 boys and 29 girls and the results were very encouraging for the use of the approach in early ASD screening.

Pathologic tearfulness after limbic encephalitis: A novel disorder and its neural basis.

OBJECTIVE: We investigated the nature and neural foundations of pathologic tearfulness in a uniquely large cohort of patients who had presented with autoimmune limbic encephalitis (aLE). METHODS: We recruited 38 patients (26 men, 12 women; median age 63.06 years; interquartile range [IQR] 16.06 years) in the postacute phase of aLE who completed questionnaires probing emotion regulation. All patients underwent structural/functional MRI postacutely, along with 67 age- and sex-matched healthy controls (40 men, 27 women; median age 64.70 years; IQR 19.87 years). We investigated correlations of questionnaire scores with demographic, clinical, neuropsychological, and brain imaging data across patients. We also compared patients diagnosed with pathologic tearfulness and those without, along with healthy controls, on gray matter volume, resting-state functional connectivity, and activity. RESULTS: Pathologic tearfulness was reported by 50% of the patients, while no patient reported pathologic laughing. It was not associated with depression, impulsiveness, memory impairment, executive dysfunction in the postacute phase, or amygdalar abnormalities in the acute phase. It correlated with changes in specific emotional brain networks: volume reduction in the right anterior hippocampus, left fusiform gyrus, and cerebellum, abnormal hippocampal resting-state functional connectivity with the posteromedial cortex and right middle frontal gyrus, and abnormal hemodynamic activity in the left fusiform gyrus, right inferior parietal lobule, and ventral pons. CONCLUSIONS: Pathologic tearfulness is common following aLE, is not a manifestation of other neuropsychiatric features, and reflects abnormalities in networks of emotion regulation beyond the acute hippocampal focus. The condition, which may also be present in other neurologic disorders, provides novel insights into the neural basis of affective control and its dysfunction in disease.

The crying child; physiological variant on F18-FDG PET-CT in a patient of langerhans cell histiocytosis.

F18-FDG PET-CT (Fluorodeoxyglucose Positron Emission Computed Tomography) scanning has a proven role in the staging of various cancers;the physiological distribution of F18-FDG must be understood thoroughly in order to improve the accuracy of image interpretation. We describe the case of a 2 year old child with Langerhans cell histiocytosis, who cried at the time of cannulation before undergoing F18-FDG PET-CT scanning.

Signs and symptoms associated with digestive tract development / Sinais e sintomas associados com o desenvolvimento do trato digestivo

ABSTRACT Objective: To analyze the development and prevalence of gastrointestinal signs and symptoms associated with the development of the digestive tract, and to assess the measures aimed to reduce their negative impacts. Source of data: Considering the scope and comprehensiveness of the subject, a systematic review of the literature was not carried out. The Medline database was used to identify references that would allow the analysis of the study topics. Synthesis of results: Infants frequently show several gastrointestinal signs and symptoms. These clinical manifestations can be part of gastrointestinal functional disorders such as infantile colic, infant regurgitation, and functional constipation. Allergy to cow's milk protein and gastroesophageal reflux disease are also causes of these clinical manifestations and represent an important and difficult differential diagnosis. The diseases that course with gastrointestinal signs and symptoms can have an impact on family dynamics and maternal emotional status, and may be associated with future problems in the child's life. Comprehensive pediatric care is essential for diagnosis and treatment. Maternal breastfeeding should always be maintained. Some special formulas can contribute to the control of clinical manifestations depending on the established diagnosis. Conclusion: During the normal development of the digestive tract, several gastrointestinal signs and symptoms may occur, usually resulting from functional gastrointestinal disorders, gastroesophageal reflux disease, and allergy to cow's milk protein. Breastfeeding should always be maintained.

RESUMO Objetivo: Analisar o desenvolvimento e a prevalência de sinais e sintomas gastrintestinais associados com o desenvolvimento do tubo digestivo e as medidas que visam a diminuir suas repercussões negativas. Fontes dos dados: Considerando a abrangência e amplitude do tema, não foi feita revisão sistemática da literatura. Usou-se a base de dados do Medline para a identificação de referências bibliográficas que permitissem contemplar os temas de estudo. Síntese dos resultados: O lactente apresenta com elevada frequência sinais e sintomas gastrintestinais. Essas manifestações clínicas podem fazer parte de distúrbios funcionais gastrintestinais, como cólica, regurgitação e constipação intestinal funcional. A alergia à proteína do leite de vaca e a doença do refluxo gastroesofágico também são causas dessas manifestações clínicas e representam um importante e difícil diagnóstico diferencial. As doenças que cursam com sintomas e sinais gastrintestinais podem ter consequências na dinâmica familiar e no estado emocional das mães. Podem se associar com problemas na vida futura da criança. A atenção pediátrica completa é fundamental para o diagnóstico e o tratamento. O aleitamento natural deve sempre ser mantido. Algumas fórmulas especiais podem contribuir para o controle das manifestações clínicas na dependência do diagnóstico estabelecido. Conclusão: Durante o desenvolvimento normal do tubo digestivo podem ocorrer sinais e sintomas gastrintestinais em geral decorrentes dos distúrbios gastrintestinais funcionais, da doença do refluxo gastroesofágico e da alergia à proteína do leite de vaca. Aleitamento natural deve sempre ser mantido.

Excessive crying in infants / Excessive crying in infants

ABSTRACT Objective: Review the literature on excessive crying in young infants, also known as infantile colic, and its effects on family dynamics, its pathophysiology, and new treatment interventions. Data source: The literature review was carried out in the Medline, PsycINFO, LILACS, SciELO, and Cochrane Library databases, using the terms “excessive crying,” and “infantile colic,” as well technical books and technical reports on child development, selecting the most relevant articles on the subject, with emphasis on recent literature published in the last five years. Summary of the findings: Excessive crying is a common symptom in the first 3 months of life and leads to approximately 20% of pediatric consultations. Different prevalence rates of excessive crying have been reported, ranging from 14% to approximately 30% in infants up to 3 months of age. There is evidence linking excessive crying early in life with adaptive problems in the preschool period, as well as with early weaning, maternal anxiety and depression, attention deficit hyperactivity disorder, and other behavioral problems. Several pathophysiological mechanisms can explain these symptoms, such as circadian rhythm alterations, central nervous system immaturity, and alterations in the intestinal microbiota. Several treatment alternatives have been described, including behavioral measures, manipulation techniques, use of medication, and acupuncture, with controversial results and effectiveness. Conclusion: Excessive crying in the early months is a prevalent symptom; the pediatrician's attention is necessary to understand and adequately manage the problem and offer support to exhausted parents. The prescription of drugs of questionable action and with potential side effects is not a recommended treatment, except in extreme situations. The effectiveness of dietary treatments and use of probiotics still require confirmation. There is incomplete evidence regarding alternative treatments such as manipulation techniques, acupuncture, and use of the herbal supplements and behavioral interventions.

RESUMO Objetivo: Revisar a literatura sobre choro excessivo em bebês pequenos e cólicas infantis e suas repercussões na família e a fisiopatologia e as estratégias de tratamento. Fonte dos dados: Revisadas as principais bases de dados, Medline, PsycINFO, Lilacs e SciELO e Cochrane Library com o uso das expressões “choro excessivo do lactente” e “cólicas do lactente”. Foram selecionadas as publicações mais relevantes com ênfase nos últimos cinco anos. Síntese dos dados: É um sintoma comum nos primeiros meses de vida e é motivo de cerca de 20% das consultas pediátricas. As prevalências de choro excessivo variam de 14 a 30% nesses lactentes. Existem evidências que ligam o choro excessivo nos primeiros meses de vida com problemas futuros, bem como ao desmame precoce, à ansiedade, à depressão materna, ao transtorno do déficit de atenção/hiperatividade (TDAH) e a outros problemas comportamentais. Distintos mecanismos fisiopatológicos podem explicar esse quadro clínico, como alterações no ritmo circadiano, imaturidade do SNC e alterações na microbiota intestinal. São descritas opções de tratamento, desde medidas comportamentais, técnicas manipulativas e uso de medicação até acupuntura, com resultados e eficácia controversos. Conclusão: Para o choro excessivo nos primeiros meses é necessária a atenção do pediatra para o entendimento e manejo do problema e oferecer apoio para pais em exaustão. A prescrição de drogas de efeitos duvidosos e potenciais efeitos colaterais não é terapêutica preconizada, a não ser em situações extremas. A eficácia dos tratamentos dietéticos e o uso de probióticos ainda necessitam de confirmação. Existem evidências incompletas a respeito de tratamentos opcionais, como técnicas manipulativas, acupuntura, uso de suplemento à base de ervas e intervenções comportamentais.

Pathological crying and emotional vasovagal syncope as symptoms of a dorsally exophytic medullary tumor.

A 3-year-old boy with a dorsally exophytic tumor arising from the rostral medulla presented with a chief complaint of a change in his emotional behavior, most notably anxiety and paroxysmal crying often followed by syncope. Magnetic resonance imaging revealed that the tumor pushed on the dorsal surface of the medulla and displaced the medulla anteriorly, and also displaced the cerebellar vermis upward and slightly posteriorly. Tissue from a partial resection was diagnosed as a pilocytic astrocytoma. The symptoms did not improved after surgery, but did improve clinically after chemotherapy with vincristine and carboplatin, at which time MR showed a reduction in tumor size. We diagnosed the paroxysmal crying as 'pathological crying' and the syncope with increased anxiety as 'emotional vasovagal syncope'. This case stresses the importance of recognition of this rare presentation as an indication of a medullary tumor.

[Cayler syndrome: A case report and review of the literature]. / Syndrome de Cayler : à propos d'un cas et revue de la littérature.

BACKGROUND AND PURPOSE: Facial asymmetries to the tears are rare. We report a pediatric original case that may fall within the framework of a Cayler syndrome. Through its clinical presentation, we will discuss differential diagnoses, associated forms, its etiology, and its management. CASE REPORT: At the maternity unit, in a male infant, after vaginal delivery at term without extraction, was discovered a lack of mobility of the labial commissure on the right side, only when crying. The rest of the examination was unremarkable, except ipsilateral microtia. Genetically, karyotype was 46,XY, 22q11 without microdeletion. The head and neck MRI and echocardiogram were normal. DISCUSSION AND CONCLUSION: Asymmetry with tears has been described in the literature, through association with microdeletion 22q11 syndrome. The originality of this case was the presence of an isolated muscle abnormality. Muscles affected by this syndrome are: Musculus depressor labii inferioris, the Depressor anguli oris, and Mentalis musculus. The three muscles can be affected concomitantly. Isolated involvment of the Depressor anguli oris muscle has also been described. The mechanical dysfunction can be either linked to muscle innervation agenesis or to a defect thereof. There is no specific treatment. The symptoms improve with age by decreasing the frequency of crying. However, it is important to know this pathology in order to seek an optimum balance further in search of associated abnormalities (FISH 22q11, cardiac Doppler ultrasound) but also to educate, to reassure families often worried by the situation.

Excessively crying infants are more common among children of parents with restless legs syndrome / Bebes com choro e agitação excessivos têm mais comumente pais com síndrome de pernas inquietas

OBJECTIVE: We have frequently observed that infants presenting with excessive crying and fussing, or colic at night have parents with Restless Legs Syndrome. Our objective was to determine if these infants are more likely to have parents with Restless Legs Syndrome (Willis-Ekbom Disease). METHODS: We interviewed 67 families with infants and children, in search of a history of excessive crying and fussing during their first four months of life. Their parents were investigated for Restless Legs Syndrome. RESULTS: Among the 134 interviewed parents, 39 (29%) had Restless Legs Syndrome. Among the 96 children, 37 (38%) presented excessive crying and fussing. Of these, 28 (76%) had at least one parent with Restless Legs Syndrome. Among the 59 children without excessive crying and fussing only 14 (24%) had at least one parent with Restless Legs Syndrome. The association between events (children of parents with vs. without Restless Legs Syndrome) was measured by the phi coefficient (0.510), indicating a more than trivial association. The estimated association was 75.7 vs. 27.7, Odds Ratio = 10 at 95% confidence interval, 3.82-26.15). CONCLUSION: Children with excessive crying and fussing were more likely to have at least one parent with Restless Legs Syndrome. The present evidence is insufficient to conclude that infantile excessive crying and fussing is equivalent to a a probable diagnosis of parental Restless Legs Syndrome. However, they provide information as well as the necessary motivation to undertake more extensive studies of infants with excessive crying and fussing.

OBJETIVO: Temos frequentemente observado que infantes que apresentam choro excessivo e agitação ou cólicas noturnas têm pais com Síndrome de Pernas Inquietas. Nosso objetivo foi determinar se estes infantes são mais propensos a terem pais com a Síndrome de Pernas Inquietas. MÉTODOS. Foram entrevistadas 67 famílias com infantes e crianças em busca de uma história de choro excessivo e agitação durante os primeiros 4 meses de vida. Seus pais foram investigadas para Síndrome de Pernas Inquietas. RESULTADOS: Dentre os 134 pais entrevistados, 39 (29%) tinham doença Willis-Ekbom. Entre as 96 crianças avaliadas 37 (38%) apresentaram choro excessivo e agitação. Destas, 28 (76%) apresentaram pelo menos um dos pais com Síndrome de Pernas Inquietas. Entre as 59 crianças sem choro excessivo e agitação, apenas 14 (23, 7%) apresentaram pelo menos um dos pais com a Síndrome de Pernas Inquietas. A associação entre os eventos (crianças de pais com ou sem Síndrome de Pernas Inquietas) foi medida pelo coeficiente phi (0,510), indicando uma associação mais do que trivial. As crianças com choro excessivo e agitação mostraram-se mais propensas a ter pelo menos um dos pais com a doença Willis-Ekbom (75,7 vs. 27,7, “Odds Ratio” = 10, com intervalo de confiança de 95%, 3,82-26,15). CONCLUSÃO: A evidência gerada por este estudo não é suficiente para concluir que o choro infantil excessivo e agitação é equivalente a um diagnóstico provável da doença Willis-Ekbom parental. No entanto, eles fornecem informações, bem como a motivação necessária para empreender estudos mais extensos sobre bebês com choro excessivo e agitação.

Respiratory inhibition after crying and feeding hypoxemia in infants.

OBJECTIVE: To determine the incidence, risk factors and natural history of respiratory inhibition after crying (RIAC) and feeding hypoxemia. METHODS: We screened for RIAC and feeding hypoxemia among 393 infants with a gestational age ≥ 36 weeks using pulse oximetry. Twenty-seven infants were treated in the neonatal intensive care unit. RESULTS: RIAC and feeding hypoxemia were observed in 95 (24.2%) and 124 (31.6%) infants, respectively. RIAC correlated with feeding hypoxemia (p < 0.001), grade II increased echogenicity in the ganglionic eminence (p = 0.005), dilation of the lateral ventricle (p = 0.044), threatened premature labor (p = 0.033) and twin gestation (p = 0.089). Feeding hypoxemia correlated with RIAC (p < 0.001), abnormal cranial ultrasound findings (p < 0.001), maternal smoking during pregnancy (p = 0.083), asymmetric intrauterine growth restriction (p = 0.012) and twin gestation (p = 0.067). All infants recovered from RIAC in an average of 4.5 (2.0-7.0) d. Fifteen infants recovered from feeding hypoxemia, but 10 infants needed additional assistance and monitoring by nursing until the day of discharge. The day of discharge was day 8.0 (5.0-12.4). CONCLUSIONS: RIAC and feeding hypoxemia are observed among healthy infants, and these infants experience repeated events of prolonged hypoxemia.

Crying with sorrow evoked by electrocortical stimulation.

Dacrystic seizures are rare and have been reported in patients with hypothalamic hamartoma as well as fronto-temporal epilepsy, involving the non-dominant hemisphere. We describe the first reported case of cortical stimulation of the left posterior orbito-frontal gyrus, generating consistent and reproducible crying with affective content in a 41-year-old woman with medically intractable left temporal lobe epilepsy, who underwent extraoperative intracranial video-EEG monitoring for resective non-lesional epilepsy surgery.

The "postcricoid cushion": observations on the vascular anatomy of the posterior cricoid region.

OBJECTIVE: To describe the cyclical vascular enlargement that occurs in the postcricoid region during the expiratory phase on an infant's cry, and to consider the anatomic, physiologic, and clinical implications of this phenomenon, which we term the "postcricoid cushion." DESIGN: A total of 125 consecutive office fiber-optic laryngoscopic examinations in children and infants were reviewed for engorgement and vascular discoloration of the postcricoid region. Presence of a postcricoid cushion in relation to patient age was reviewed. A comprehensive literature review was also performed. SETTING: Tertiary care pediatric hospital. PATIENTS: Patients from newborns to 17 years old undergoing laryngoscopy for any reason. RESULTS: Sixty-one percent of the videos showed a postcricoid cushion with cyclical enlargement during crying. Eighty-eight percent of children younger than 24 months had presence of a cushion compared with only 38% of children 24 months or older (P < .001). Twenty-five percent of the cushions had violaceous discoloration that resembled a vascular malformation. CONCLUSIONS: Anatomic studies have demonstrated a rich venous plexus in the postcricoid region of the larynx. During the expiratory phase of an infant's cry, there is a cyclical engorgement, occasionally with vascular discoloration, in the postcricoid region at the same level of the venous plexus-the "postcricoid cushion." We propose that during crying, with acute elevation in intrathoracic pressure, there is a filling of the plexus, causing apposition of the postcricoid cushion against the posterior pharyngeal wall, which may serve as a protective barrier to emesis in infants. Our observations relate and differentiate this normal physiologic phenomenon from the rare cases of postcricoid vascular anomalies.

Lingual frenulum protocol with scores for infants.

An experimental protocol model for frenulum evaluation was first designed, and administered to ten infants in 2010. After obtaining the data and statistical analysis, the protocol was re-designed and administered to 100 infants. The aim of this study is to present an efficient and effective lingual frenulum protocol with scores for infants. From the experimental protocol model, a new protocol was designed. One speech-language pathologist, and specialist in orofacial myology, administered the new protocol to 100 full-term infants. All steps of the protocol were recorded and photographed. The data collected was sent to two specialists in the area, who evaluated the cases based on the recordings and photographs. The data from the three evaluations were compared. A two-part protocol was designed to evaluate the lingual frenulum in infants. The first part consists of clinical history with specific questions about family history and breastfeeding. The second part consists of clinical examination: anatomo-functional, non-nutritive and nutritive sucking evaluations. A new lingual frenulum protocol with scores for infants was designed, and has proved to be an effective tool for health professionals to assess and diagnose anatomical alterations of the lingual frenulum, and its possible interference with breastfeeding.

Asphyxia screening kit.

Infant asphyxia is a condition due to insufficient oxygen intake suffered by newborn babies. A 4 to 9 million occurrences of infant asphyxia are reported each year by WHO. Early diagnosis of asphyxia is important to avoid complications such as damage to the brain, organ and tissue that could lead to fatality. This is possible with the automation of screening of infant asphyxia. Here, a non-invasive Asphyxia Screening Kit is developed. It is a Graphical User Interface that automatically detects asphyxia in infants from early birth to 6 months from their cries and displays the outcome of analysis. It is built with Matlab GUI underlied with signal processing algorithms, capable of achieving a classification accuracy of 96.03%. Successful implementation of ASK will assist to screen infant asphyxia for reference to clinicians for early diagnosis. In addition, ASK also provides an interface to enter patient information and images to be integrated with existing Hospital Information Management System.

[Neurology of laughter and humour: pathological laughing and crying]. / Neurología de la risa y del humor: risa y llanto patológicos.

INTRODUCTION: Laughter, which is usually a healthy biological phenomenon, may be also a symptom of several severe brain pathologies. AIM: To review the neurobiological bases of laughter and humour, as well as those of pathological laughing and crying syndrome. DEVELOPMENT: At the mesencephalic-pontine junction there is a central coordinator of the nuclei that innervate the muscles involved in laughter (facial expression, respiratory and phonatory). This centre receives connections from three systems: inhibitory (pre-motor and motor cortex), excitatory (temporal cortex, amygdala, hypothalamus) and modulator (cerebellum). Humour is a complex phenomenon with a range of components: the perception of the unexpected incongruence (occipitotemporal area, prefrontal cortex), emotional (reward circuit) and volitional (temporal and frontal cortex). Functional magnetic resonance imaging studies do not reveal a markedly prominent role of the right frontal lobe in processing humour, as had been suggested in the classical studies. The causes of pathological laughing and crying syndrome can be classified in two groups: altered behaviour with unmotivated happiness (Angelman syndrome, schizophrenia, manias, dementia) and interference with the inhibitory/excitatory mechanisms (gelastic epilepsy, fou rire prodromique in strokes, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease and Parkinson-plus, traumatic injuries, tumours). Serotonin and noradrenalin reuptake inhibitors, levodopa, lamotrigine and the association of dextromethorphan/quinidine can be effective in certain cases of pathological laughing and crying. CONCLUSIONS: As human neurobiological phenomena, laughter and humour also belong to the field of clinical neurology; their processing is affected in a number of different diseases and, in certain cases, effective treatment can be established.

Effectiveness and acceptability of intravenous sedation in child and adolescent dental patients: report of a case series at King's College Hospital, London.

INTRODUCTION: Conscious sedation for young patients continues to be challenging. Few studies have shown positive results using intravenous midazolam when sedating young patients. This case series reports an investigation of conscious sedation using intravenous midazolam for young patients receiving dental treatment. OBJECTIVE: To determine acceptance, safety and efficacy of intravenous midazolam for conscious sedation in children and adolescent patients undergoing dental treatment.Patients and methods Patients from seven to 16 years of age, ASA I, II and III, opted to have extractions, minor oral surgery and/or conservative treatment with IV midazolam and local anaesthesia. A pulse oximeter was used to monitor vital signs and the Houpt scale to assess overall behaviour. RESULTS: A total of 552 patients, 234 boys and 318 girls with mean ages of 13.3 years and 13.5 years respectively, were included. Three hundred and sixty-five patients (66%) claimed to be anxious or very anxious before treatment. The average dose given was 5.7 mg and dosage ranged from 2 to 10 mg. Four hundred and fifty-seven patients (83%) scored 'very good' and 'excellent' for overall behaviour. Side-effects included crying, drowsiness and amnesia. CONCLUSIONS: Intravenous midazolam is accepted by patients and is a safe and effective method of sedation for use in children and adolescents, producing some level of tearfulness.

Effective method for screening for respiratory inhibition after crying in infants.

BACKGROUND: In order to establish an effective screening method for respiratory inhibition after crying (RIAC), we prospectively studied the correlations between infant RIAC and perinatal factors. METHODS: We monitored infants (n=141) born from May through July 2009 with polygraphy and evaluated the presence of RIAC and respiratory pause that occurred when feeding was initiated immediately after crying with a decrease in oxygen saturation (SpO(2) ) to <60%. The infants were screened for increased echogenicity, a cyst in the ganglionic eminence (GE), or a subependymal cyst by cranial ultrasound. Furthermore, we evaluated the correlations between RIAC and perinatal factors. RESULTS: Eleven infants displayed RIAC and 31 experienced respiratory pause during feeding with a decrease in SpO(2) to <60%. There were no significant correlations between RIAC and perinatal factors. Forty infants had ultrasound abnormalities (increased echogenicity in the GE, 26; cyst in the GE, nine; and subependymal cyst, seven). Sensitivity, specificity, and efficiency of abnormal cranial ultrasound findings for RIAC were 1.00, 0.777, and 0.794, respectively. The odds ratio, sensitivity, specificity, and efficiency of the combination of abnormal cranial ultrasound findings and respiratory pause during feeding with a decrease in SpO(2) to <60% and RIAC were 35.9 (P<0.001), 0.727, 0.931, and 0.915, respectively. CONCLUSION: The combination of abnormal cranial ultrasound findings and respiratory pause during feeding with a decrease in SpO(2) appears to be an effective method of screening for RIAC.

Might asphyxia cause respiratory inhibition after crying in mature infants?

BACKGROUND: To clarify the timing of injury in utero causing respiratory inhibition after crying (RIAC), the relationship between asphyxia and RIAC was investigated in infants whose gestational age was ≥ 36 weeks. METHODS: RIAC and cranial ultrasound abnormalities were examined for retrospectively in infants treated in the neonatal intensive care unit from April 2004 through March 2009. All included infants were gestational age ≥ 36 weeks and had an Apgar score <4 points at 1 min. The relationship between RIAC and perinatal factors was also examined. RESULTS: Twenty-six infants were included. Three infants had RIAC, seven infants had poor prognosis, and nine infants had ultrasound abnormalities in the ganglionic eminence (GE). There was a significant relationship between RIAC and ultrasound abnormalities in the GE (P= 0.032). Poor prognosis was significantly associated with low Apgar score at 5 min (P ≤ 0.001), disseminated intravascular coagulation (P= 0.047), hypoxic ischemic encephalopathy (P= 0.028), and brain hypothermia therapy (P= 0.028). There was no significant relationship between RIAC and poor prognosis. All infants had ultrasound abnormalities in the GE on the day of birth. CONCLUSION: Damage occurring in utero prior to 36 weeks gestation might cause increased echogenicity or cyst formation in the GE, potentially disturbing maturation of the respiratory center with the development of RIAC.

Crying with left temporal lobe seizures and Wada testing.

Dacrystic seizures are characterized by crying and are rare in patients with epilepsy. The crying that occurs during complex partial seizures is expressed as an unconscious behavior unassociated with sadness or depressive quality. It has been reported to occur with focal seizures that are localized to the frontotemporal regions and is frequently lateralized to the nondominant hemisphere. We describe a woman with left temporal lobe epilepsy and recurrent complex partial seizures with crying behavior that was reproduced during left carotid methohexital anesthesia, suggesting functional inactivation by two different mechanisms. Following left amygdalohippocampectomy she became seizure free for >2years without perioperative mood destabilization. Localized functional networks that involve limbic structures may be involved in patients with dacrystic seizures with a favorable outcome following epilepsy surgery.

Pathological crying as a manifestation of spontaneous haemorrhage in a pontine cavernous haemangioma.

A 53-year-old man presented with a sudden onset severe headache associated with ataxia. His family observed labile emotions and frequent episodes of crying. Investigations revealed a pontine cavernoma with evidence of bleeding. The lesion was treated conservatively. Over approximately 6 months, the patient's ataxia improved and he recovered from the crying episodes. To our knowledge, pathological crying has not been previously associated with brainstem cavernoma.