The influence of the addition of surfactants to sodium hypochlorite on the removal of hard tissue debris.

AIM: To evaluate the effect of the addition of surfactants to sodium hypochlorite (NaOCl) on the removal of accumulated hard tissue debris (AHTD), before and after final irrigation with 17% EDTA, from mesial canals of mandibular molars through microcomputed tomographic (micro-CT) analysis. METHODOLOGY: Thirty moderately curved mandibular mesial roots with Vertucci type II canal configuration were selected and scanned in a micro-CT device at an isotropic resolution of 22.9 µm. The specimens were assigned to three groups (n = 10) with respect to the root length, degree of curvature of the mesial root, volume and 3D anatomy of the root canals according to the irrigating solution used during root canal preparation: 2.5% NaOCl and 0.1% Benzalkonium Chloride, 2.5% NaOCl and 0.1% Tween 80 and 2.5% NaOCl without additives. The root canals were instrumented up to Reciproc R25 instrument. Then, the specimens were scanned again after canal preparation and after final irrigation with 17% EDTA, and the registered data sets were examined to evaluate the percentage of AHTD. For comparison between the different groups before and after using 17% EDTA, the Kruskal-Wallis test was used with a significance level of 5%. For comparison between the same groups before and after using 17% EDTA, the Wilcoxon test was used with a significance level of 5%. RESULTS: None of the irrigant solutions tested was able to completely eliminate hard tissue debris from mesial canals of mandibular molars. There were no significant differences in the percentage of AHTD amongst the different irrigation solutions (P > 0.05). Final irrigation with 17% EDTA significantly reduced the percentage of AHTD (P < 0.05), without differences amongst the groups (P > 0.05). CONCLUSIONS: The addition of surfactants to NaOCl did not affect the removal of AHTD from mesial canals of extracted mandibular molars. Final irrigation with 17% EDTA significantly improved AHTD removal.

Increased titer and reduced lactate accumulation in recombinant retrovirus production through the down-regulation of HIF1 and PDK.

Many mammalian cell lines used in the manufacturing of biopharmaceuticals exhibit high glycolytic flux predominantly channeled to the production of lactate. The accumulation of lactate in culture reduces cell viability and may also decrease product quality. In this work, we engineered a HEK 293 derived cell line producing a recombinant gene therapy retroviral vector, by down-regulating hypoxia inducible factor 1 (HIF1) and pyruvate dehydrogenase kinase (PDK). Specific productivity of infectious viral titers could be increased more than 20-fold for single gene knock-down (HIF1 or PDK) and more than 30-fold under combined down-regulation. Lactate production was reduced up to 4-fold. However, the reduction in lactate production, alone, was not sufficient to enhance the titer: high-titer clones also showed significant enrollment of metabolic routes not related to lactate production. Transcriptome analysis indicated activation of biological amines metabolism, detoxification routes, including glutathione metabolism, pentose phosphate pathway, glycogen biosynthesis and amino acid catabolism. The latter were validated by enzyme activity assays and metabolite profiling, respectively. High-titer clones also presented substantially increased transcript levels of the viral genes expression cassettes. The results herein presented demonstrate the impact of HIF1 and PDK down-regulation on the production performance of a mammalian cell line, reporting one of the highest fold-increase in specific productivity of infectious virus titers achieved by metabolic engineering. They additionally highlight the contribution of secondary pathways, beyond those related to lactate production, that can be also explored to pursue improved metabolic status favoring a high-producing phenotype.

Impact of adenovirus life cycle progression on the generation of canine helper-dependent vectors.

Helper-dependent adenovirus vectors (HDVs) are safe and efficient tools for gene transfer with high cloning capacity. However, the multiple amplification steps needed to produce HDVs hamper a robust production process and in turn the availability of high-quality vectors. To understand the factors behind the low productivity, we analyzed the progression of HDV life cycle. Canine adenovirus (Ad) type 2 vectors, holding attractive features to overcome immunogenic concerns and treat neurobiological disorders, were the focus of this work. When compared with E1-deleted (ΔE1) vectors, we found a faster helper genome replication during HDV production. This was consistent with an upregulation of the Ad polymerase and pre-terminal protein and led to higher and earlier expression of structural proteins. Although genome packaging occurred similarly to ΔE1 vectors, more immature capsids were obtained during HDV production, which led to a ~4-fold increase in physical-to-infectious particles ratio. The higher viral protein content in HDV-producing cells was also consistent with an increased activation of autophagy and cell death, in which earlier cell death compromised volumetric productivity. The increased empty capsids and earlier cell death found in HDV production may partially contribute to the lower vector infectivity. However, an HDV-specific factor responsible for a defective maturation process should be also involved to fully explain the low infectious titers. This study showed how a deregulated Ad cycle progression affected cell line homeostasis and HDV propagation, highlighting the impact of vector genome design on virus-cell interaction.

Single-step cloning-screening method: a new tool for developing and studying high-titer viral vector producer cells.

This article describes a novel method merging the cloning of viral vector producer cells with vector titer screening, allowing for screening 200-500 clones in 2 weeks. It makes use of a GFP separated into two fragments, S10 and S11 (Split GFP), fluorescing only upon transcomplementation. Producer cells carrying a S11 viral transgene are cloned in 96-well plates and co-cultured with target cells stably expressing S10. During the period of clone expansion, S11 viruses infect S10 target cells reconstituting the GFP signal. Transcomplemented fluorescence data provide direct estimation of the clone's productivity and can be analyzed in terms of density distribution, offering valuable information on the average productivity of the cell population and allowing the identification of high-producing clones. The method was validated by establishing a retrovirus producer from a nude cell line, in <3 months, inserting three vector constructs without clone selection or screening in between. Clones producing up to 10(8) infectious particles per ml were obtained, delivering optimal ratios of infectious-to-total particles (1 to 5). The method was additionally used to evaluate the production performance of HEK 293 and HEK 293T cell lines demonstrating that the latter sustains increased titers. Finally, it was used to study genetic manipulation of glutathione metabolism in retrovirus production showing that changing cell metabolism steers higher vector expression with titer increases of more than one order of magnitude.This method is a valuable tool not only for cell line development but also for genetic manipulation of viral vector and/or producer cells contributing to advancing the field of viral gene therapy.

One fungus, which genes? Development and assessment of universal primers for potential secondary fungal DNA barcodes.

The aim of this study was to assess potential candidate gene regions and corresponding universal primer pairs as secondary DNA barcodes for the fungal kingdom, additional to ITS rDNA as primary barcode. Amplification efficiencies of 14 (partially) universal primer pairs targeting eight genetic markers were tested across > 1 500 species (1 931 strains or specimens) and the outcomes of almost twenty thousand (19 577) polymerase chain reactions were evaluated. We tested several well-known primer pairs that amplify: i) sections of the nuclear ribosomal RNA gene large subunit (D1-D2 domains of 26/28S); ii) the complete internal transcribed spacer region (ITS1/2); iii) partial ß -tubulin II (TUB2); iv) γ-actin (ACT); v) translation elongation factor 1-α (TEF1α); and vi) the second largest subunit of RNA-polymerase II (partial RPB2, section 5-6). Their PCR efficiencies were compared with novel candidate primers corresponding to: i) the fungal-specific translation elongation factor 3 (TEF3); ii) a small ribosomal protein necessary for t-RNA docking; iii) the 60S L10 (L1) RP; iv) DNA topoisomerase I (TOPI); v) phosphoglycerate kinase (PGK); vi) hypothetical protein LNS2; and vii) alternative sections of TEF1α. Results showed that several gene sections are accessible to universal primers (or primers universal for phyla) yielding a single PCR-product. Barcode gap and multi-dimensional scaling analyses revealed that some of the tested candidate markers have universal properties providing adequate infra- and inter-specific variation that make them attractive barcodes for species identification. Among these gene sections, a novel high fidelity primer pair for TEF1α, already widely used as a phylogenetic marker in mycology, has potential as a supplementary DNA barcode with superior resolution to ITS. Both TOPI and PGK show promise for the Ascomycota, while TOPI and LNS2 are attractive for the Pucciniomycotina, for which universal primers for ribosomal subunits often fail.

[Clinical stages of patients with Alzheimer disease treated in specialist clinics in Spain. The EACE study]. / Estadio evolutivo de los pacientes con enfermedad de Alzheimer que acuden a la consulta especializada en España. Estudio EACE.

INTRODUCTION: The diagnostic paradigm of Alzheimer disease (AD) is changing; there is a trend toward diagnosing the disease in its early stages, even before the complete syndrome of dementia is apparent. The clinical stage at which AD is usually diagnosed in our area is unknown. Therefore, the purpose of this study is to describe the clinical stages of AD patients at time of diagnosis. METHODS: Multicentre, observational and cross-sectional study. Patients with probable AD according to NINCDS-ARDRA criteria, attended in specialist clinics in Spain, were included in the study. We recorded the symptom onset to evaluation and symptom onset to diagnosis intervals and clinical status of AD (based on MMSE, NPI questionnaire, and CDR scale). RESULTS: Participants in this study included 437 specialists representing all of Spain's autonomous communities and a total of 1,707 patients, of whom 1,694 were included in the analysis. Mean MMSE score was 17.6±4.8 (95% CI:17.4-17.9). Moderate cognitive impairment (MMSE between 10 and 20) was detected in 64% of the patients, and severe cognitive impairment (MMSE<10) in 6%. The mean interval between symptom onset and the initial primary care visit was 10.9±17.2 months (95% CI:9.9-11.8), and the interval between symptom onset and diagnosis with AD was 28.4±21.3 months. CONCLUSIONS: Results from the EACE show that most AD patients in our area have reached a moderate clinical stage by the time they are evaluated in a specialist clinic.

In vitro assessment of the combined effect of letermovir and sirolimus on cytomegalovirus replication.

OBJECTIVE: Letermovir (LMV) is used for prophylaxis of cytomegalovirus (CMV) reactivation and end-organ disease in adult CMV-seropositive allogeneic hematopoietic stem cell transplant recipients (allo-HSCT). In turn, sirolimus (SLM) which displays in vitro anti-CMV activity, is frequently employed for prophylaxis of Graft vs. Host disease in allo-HSCT. Here, we aimed at assessing whether LMV and SLM used in combination may act synergistically in vitro on inhibiting CMV replication. METHODS: The antiviral activity of LMV and SLM alone or in combination was evaluated by a checkerboard assay, using ARPE-19 cells infected with CMV strain BADrUL131-Y. LMV and SLM were used at concentrations ranging from 24 nM to 0.38 nM and 16 nM to 0.06 nM, respectively. RESULTS: The mean EC50 for LMV and SLM was 2.44 nM (95% CI, 1.66-3.60) and 1.40 nM (95% CI, 0.41-4.74), respective. LMV and SLM interaction yielded mainly additive effects over the range of concentrations tested. CONCLUSIONS: The additive nature of the combination of LMV and SLM against CMV may have relevant clinical implications in management of CMV infection in allo-HSCT recipients undergoing prophylaxis with LMV.

What makes transposable elements move in the Drosophila genome?

Transposable elements (TEs), by their capacity of moving and inducing mutations in the genome, are considered important drivers of species evolution. The successful invasions of TEs in genomes, despite their mutational properties, are an apparent paradox. TEs' transposition is usually strongly regulated to low value, but in some cases these elements can also show high transposition rates, which has been associated sometimes to changes in environmental conditions. It is evident that factors susceptible to induce transpositions in natural populations contribute to TE perpetuation. Different factors were proposed as causative agents of TE mobilization in a wide range of organisms: biotic and abiotic stresses, inter- and intraspecific crosses and populational factors. However, there is no clear evidence of the factors capable of inducing TE mobilization in Drosophila, and data on laboratory stocks show contradictory results. The aim of this review is to have an update critical revision about mechanisms promoting transposition of TEs in Drosophila, and to provide to the readers a global vision of the dynamics of these genomic elements in the Drosophila genome.

Down-regulation of CD81 tetraspanin in human cells producing retroviral-based particles: tailoring vector composition.

Retroviral-derived biopharmaceuticals (RV) target numerous therapeutic applications, from gene therapy to virus-like particle (rVLP)-based vaccines. During particle formation, beside the pseudotyped envelope proteins, RV can incorporate proteins derived from the virus producer cells (VPC). This may be detrimental by reducing the amounts of the pseudotyped envelope and/or by incorporating protein capable of inducing immune responses when non-human VPC are used. Manipulating the repertoire of VPC proteins integrated onto the vector structure is an underexplored territory and should provide valuable insights on potential targets to improve vector pharmacokinetic and pharmacodynamic properties. In this work, human HEK 293 cells producing retrovirus-like particles (rVLPs) and infectious RV vectors were used to prove the concept of customizing RV composition by manipulating cellular protein content. The tetraspanin CD81 was chosen since it is significantly incorporated in the RV membrane, conferring to the vector significant immunogenicity when used in mice. RNA interference-mediated by shRNA lentiviral vector transduction was efficiently used to silence CD81 expression (up to 99%) and the rVLPs produced by knocked-down cells lack CD81. Silenced clones were analyzed for cell proliferation, morphological changes, susceptibility to oxidative stress conditions, and rVLP productivities. The results showed that the down-regulation of VPC proteins requires close monitoring for possible side effects on cellular production performance. Yet, they confirm that it is possible to change the composition of host-derived immunogens in RV by altering cellular protein content with no detriment for vector productivity and titers. This constitutes an important manipulation tool in vaccinology--by exploiting the potential adjuvant effect of VPC proteins or using them as fusion agents to other proteins of interest to be exposed on the vector membrane--and in gene therapy, by reducing the immunogenicity of RV-based vector and enhancing in vivo half-life. Such tools can also be applied to lentiviral or other enveloped viral vectors.

The use of neuropsychological tests across Europe: the need for a consensus in the use of assessment tools for dementia.

BACKGROUND AND PURPOSE: The centres dedicated to dementia throughout Europe use different neuropsychological tests in clinical practice. The European Federation of Neurological Societies task force on neuropsychological tests produced this survey on neuropsychological tests currently being used in different European countries to gather knowledge on the practice of dementia centres and to promote the harmonization of such instruments and future multicentre collaborations. METHODS: National representatives of 34 countries received a questionnaire and 25 (73.5%) sent it back. RESULTS: A few instruments, Mini-Mental State Examination (MMSE), Trail Making Test (TMT), Verbal Fluency and Clock Drawing Test, were available in all countries. Wechsler Adult Intelligence Scales and MMSE were reported to be valid, respectively, in 20 (80%) and 19 (76%) countries, whereas Verbal Fluency and Stroop Test are valid in 18 (72%) of them. Of the 25 countries, 17 have validation norms for Clock Drawing Test and TMT (68%), and Neuropsychiatric Inventory, Alzheimer's Disease Assessment Scale - Cognitive Subscale, Rey Complex Figure Test, Digit Symbol and Beck Depression Inventory were standardized in 16 countries (64%). The remaining tests were validated, at most, in about half of them. Not all countries certificate neuropsychology. CONCLUSIONS: Despite the substantial differences in the tools used by the EFNS countries for most domains surveyed by the questionnaire, there is at least one neuropsychological instrument used by about 80% of the countries. There is clearly the need for a broader consensus in the use of neuropsychological tests for dementia diagnosis.

Cut-off scores in MMSE: a moving target?

BACKGROUND: Cognitive tests are known to be influenced by language, culture and education. In addition, there may be an impact of 'epoch' in cognition, because there is secular increase in scores of IQ tests in children. If we assume this is a long lasting process, then it should persist later in life. METHODS: To test this hypothesis, we compared the performance of two cohorts of individuals (>or=50 years of age), evaluated 20 years apart using the Mini-Mental State Examination (MMSE). RESULTS: Study population included 135 participants in 1988 and 411 in 2008. MMSE scores were higher in 2008 than in 1988 for literacy x age-matched subgroups, the difference being significant for participants with lower literacy. Score variance was explained by literacy (beta = 0.479, t = 14.598, P = 0.00), epoch (beta = 0.34, t = 10.33, P = 0.00) and age (beta = -0.142, t = -4.184, P = 0.00). CONCLUSION: The present results are in accordance with a lifelong secular improvement in cognitive performance. The operational cut-off values may change with time, which may have clinical impact in the diagnosis of disorders like mild cognitive impairment or dementia.

CD56-Negative Aggressive NK Cell Leukemia Relapsing as Multiple Cranial Nerve Palsies: Case Report and Literature Review.

BACKGROUND: Aggressive natural killer cell leukemia (ANKL) is extremely rare and habitually manifests as a systemic disease with multiorgan failure that rapidly evolves to death. The neoplastic natural killer (NK) cells usually harbor the Epstein-Barr virus (EBV) with a latent viral infection pattern type II; they often have a cytoplasmic CD3ε+ and surface CD3-, CD2+, and CD56+ immunophenotype, and they show complex genetic abnormalities affecting multiple tumor suppressor genes and oncogenes. We present a rare case of CD56-negative ANKL and review the clinical and laboratorial criteria for the diagnosis, as well as the available therapies. CASE PRESENTATION: A European 36-year-old male presented with acute onset fever, pallor, weakness, and jaundice. He had hepatosplenomegaly, severe pancytopenia, hepatic cytolysis, and very high serum lactic dehydrogenase levels. The bone marrow studies resulted in the diagnosis of an EBV-positive, CD56-negative ANKL. The patient failed to respond to gemcitabine and cisplatin-based polychemotherapy, dying three months later with leukemic meningitis and multiple cranial nerves palsies. CONCLUSIONS: The diagnosis of ANKL is difficult and requires both clinical suspicion and an extensive laboratorial approach. Absence of CD56 expression on the neoplastic NK cells may impose difficulties in the diagnosis, which requires morphological, immunophenotypic, histopathological, immunohistochemical, cytogenetic, and molecular studies.

Cost-minimization analysis for Portugal of five doublet chemotherapy regimens from two phase III trials in the treatment of advanced non-small cell lung cancer.

OBJECTIVES: Economic evaluations of chemotherapy regimens for stage IIIB or IV non-small cell lung cancer (NSCLC) have been conducted for many European countries, but not for Portugal. This study evaluates the total health care costs of five commonly used doublet regimens with similar efficacy results. METHODS: Using the methodology reported by Schiller [Schiller JH, Tilden D, Aristides M, Lees M, Kielhorn A, Maniadakis N, et al. Restropective cost analysis of gemcitabine in combination with cisplatin in non-small cell lung cancer compared to other combination therapies in Europe. Lung Cancer 2004;43:101-12], we conducted a cost-minimization analysis to compare vinorelbine-cisplatin (Vin/Cis), gemcitabine-cisplatin (Gem/Cis), paclitaxel-carboplatin (Pac/Carb), docetaxel-cisplatin (Doc/Cis), and paclitaxel-cisplatin (Pac/Cis). The perspective was that of the Portuguese National Health Service and included only direct medical costs (reimbursed costs plus co-payments): chemotherapy acquisition, chemotherapy administration, hospitalizations due to adverse events, and other medical resources. Unit costs were drawn from official sources (Diagnosis Related Groups and retail/hospital costs) (2003 value [Diagnosis Related Groups (DRG) published at Diário da República; 2003]). Resource use was estimated from two multicenter randomized phase III trials [Comella P, Frasci G, Panza N, Manzione L, De Cataldis G, Cioffi R, et al. Randomized trial comparing cisplatin, gemcitabine, and vinorelbine with either cisplatin and gemcitabine or cisplatin and vinorelbine in advanced non-small-cell lung cancer: interim analysis of a phase III trial of the Southern Italy Cooperative Oncology Group. J Clin Oncol 2000;18:1451-7; Schiller JH, Harrington D, Belani CP, Langer C, Sandler A, Krook J, et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med 2002;346:92-8]. A time horizon of a full course of therapy was adopted. One-way sensitivity analyses were performed. RESULTS: The least and the most costly chemotherapy regimens were Gem/Cis and Pac/Carb, respectively. Total mean cost per patient was estimated at euro7083 for Gem/Cis and euro10,008 for Pac/Carb, a mean cost savings of euro2925 per patient for Gem/Cis. The differences were mainly due to the higher chemotherapy acquisition costs of Pac/Carb than for Gem/Cis. Gem/Cis was less costly in all sensitivity analyses except when 100% inpatient chemotherapy administration was assumed. CONCLUSION: Gem/Cis should be considered as a cost-saving alternative to the other four regimens in treating NSCLC patients in Portugal.

The mechanism of action of Cu2+ on the frog skin.

The mechanism of action of Cu2+ when applied to the external side of the frog skin preparation was investigated. Cu2+ acts most probably on the external barrier of this preparation, since it increases the transport pool of Na+ proportionally to the increase in the short circuit current (Isc). Cu2+ does not open new routes for the Na+ entry since the stimulated Isc is still completely abolished by amiloride. The Isc dependence of Na+ concentration in the external medium is modified by copper, since the Km value increases in addition to changes in V. It is suggested that copper acts at the external barrier Na channels in a way similar to that proposed by Zeiske and Lindemann ((1974) Biochim. Biophys. Acta 352, 323--326) for benzoylimidazole-2 guanidine and benzoylthiazole-2 guanidine and by Dick and Lindemann ((1975) Pflügers Arch. ges. Physiol. 355, R72) for para-chloromercuribenzenosulfonate and para-chloromercuribenzoate.

Temporal auditory processing and phonological awareness in children with benign epilepsy with centrotemporal spikes.

The aim of this research was to analyze temporal auditory processing and phonological awareness in school-age children with benign childhood epilepsy with centrotemporal spikes (BECTS). Patient group (GI) consisted of 13 children diagnosed with BECTS. Control group (GII) consisted of 17 healthy children. After neurological and peripheral audiological assessment, children underwent a behavioral auditory evaluation and phonological awareness assessment. The procedures applied were: Gaps-in-Noise test (GIN), Duration Pattern test, and Phonological Awareness test (PCF). Results were compared between the groups and a correlation analysis was performed between temporal tasks and phonological awareness performance. GII performed significantly better than the children with BECTS (GI) in both GIN and Duration Pattern test (P < 0.001). GI performed significantly worse in all of the 4 categories of phonological awareness assessed: syllabic (P = 0.001), phonemic (P = 0.006), rhyme (P = 0.015) and alliteration (P = 0.010). Statistical analysis showed a significant positive correlation between the phonological awareness assessment and Duration Pattern test (P < 0.001). From the analysis of the results, it was concluded that children with BECTS may have difficulties in temporal resolution, temporal ordering, and phonological awareness skills. A correlation was observed between auditory temporal processing and phonological awareness in the suited sample.

Headaches in intracerebral hemorrhage survivors.

Few data exist on headache in survivors of acute cerebrovascular disease. During the second year of follow-up of a cohort of intracerebral hemorrhages (ICH), the lifetime history of headache before stroke and 2 years after stroke was characterized through a neurologic interview and a headache questionnaire. Headaches were classified following the International Headache Society classification categories. Disability (Rankin scale) and depression (CERAD depression scale) were also evaluated. Ninety survivors were interviewed. Comparing the distribution of pre- and post-ICH headaches, 24 subjects (27%) never had headaches, 39 subjects (43%) had ongoing headaches, 10 subjects (11%) complained of headaches only after ICH, and 17 subjects' (19%) headaches remitted after ICH. There was usually a delay of weeks or months between ICH and the first headache episode. Poststroke headaches were in general less severe and frequent than prestroke headaches. New-onset headaches after ICH were mainly of the tension type and were significantly associated with depression but not with new intracranial lesions. Headaches in remission after ICH were related to acute alcohol consumption and migraines. Chronic post-ICH headaches are usually tension type and occur in association with depression. Remission of headaches after ICH is related to removal of headache precipitants (alcohol) and possibly to structural or functional changes of the trigeminovascular system secondary to intracranial bleeding.

Transient and persistent right ear extinction in dichotic listening: subcortical lesions.

Nine patients with aphasia had right ear extinction in dichotic listening to words in the first month after an ischemic stroke; they were reassessed after 3 months. Four showed complete recovery from the right ear extinction; in five, the abnormality persisted. In those who recovered, CT revealed a subcortical lesion lateral to the frontal horn of the lateral ventricle without a lesion of Heschl's gyrus or geniculo-temporal pathways; a lesion in those structures was found in patients who did not recover. As reported for subcortical aphasia, a subcortical mechanism may explain contralateral ear extinction in dichotic listening.

Seizure outcome and hippocampal atrophy in familial mesial temporal lobe epilepsy.

OBJECTIVE: To describe the clinical, genetic and MR characteristics of patients with familial mesial temporal lobe epilepsy (MTLE). DESIGN/METHODS: The familial occurrence of MTLE was identified by a systematic search of family history of seizures in patients followed in the authors' epilepsy clinic. All probands and, whenever possible, other affected family members underwent EEG and MR investigations. RESULTS: Twenty-two unrelated families with at least two individuals with MTLE were identified by clinical and EEG findings. Ninety-eight individuals with history of seizures were evaluated. Sixty-eight patients fulfilled the diagnostic criteria for MTLE. MRI was performed in 84 patients, and showed hippocampal atrophy with increased T2 signal in 48 (57%). The distribution of hippocampal atrophy according to the seizure outcome groups was 6 of 13 patients (46%) with seizure remission, 16 of 31 (51%) with good seizure control under medication, and all 16 patients with refractory MTLE. Hippocampal atrophy was found also in patients that did not fulfill the criteria for MTLE: 3 of 10 (30%) patients with febrile seizure alone, 6 of 10 (60%) patients with recurrent generalized tonic-clonic seizures, and 1 of 4 (25%) patients with a single partial seizure. CONCLUSION: Familial MTLE is a clinically heterogeneous syndrome. Hippocampal atrophy was observed in 57% of patients, including those with benign course or seizure remission, indicating that the relationship between hippocampal atrophy and severity of epilepsy might be more complex than previously suspected. In addition, these findings indicate the presence of a strong genetic component determining the development of mesial temporal sclerosis in these families.

Surgical treatment of epilepsy in tuberous sclerosis: strategies and results in 18 patients.

BACKGROUND: Seizures in patients with tuberous sclerosis complex (TSC) are often intractable to antiepileptic medications and searching investigation may provide evidence that surgical treatment can be considered. OBJECTIVE: To review the results of investigation and surgical therapy, a treatment modality not generally considered in patients with medically refractory seizures and TSC. METHODS: We report 18 patients (9 male) with TSC who underwent surgical treatment of medically refractory epilepsy. Twelve patients had a well-localized epileptogenic lesion and were treated by lesionectomy or focal resection. Resections were: 7 frontal, 4 temporal, 1 frontotemporal, 1 occipital, and 1 frontoparietal. Four patients underwent more than one operation. Six patients had corpus callosotomy (CC). RESULTS: Follow-up ranged from 1 month to 47 years. Outcome of the patients treated by resection was excellent in 7 (5 were seizure-free and 2 had auras only), good in 1, fair in 3, and 1 was lost to follow-up. Best outcome was obtained in patients who had focal seizures and good imaging and EEG correlation, although they might have multiple seizure types, other imaging abnormalities, and multifocal or generalized EEG findings. When there was no such correlation, CC was found to be an option as five patients had at least some improvement and only one showed no change. CONCLUSION: Surgical treatment of patients with TSC and intractable epilepsy is most effective when a single tuber or epileptogenic area can be identified as the source of seizures and resected. This may be possible even when other tubers or diffuse EEG abnormalities are present. In patients with unlocalizable epileptic abnormalities, palliation may be obtained by CC.