Lower gray matter volumes of frontal lobes and insula in adolescents with anorexia nervosa restricting type: Findings from a Brain Morphometry Study.

BACKGROUND: Brain atrophy in anorexia nervosa (AN) is one of the most marked structural brain changes observed in mental disorders. In this study, we propose a whole brain analysis approach to characterize global and regional cerebral volumes in adolescents with restricting-type anorexia nervosa (AN-r). METHODS: A total of 48 adolescent females (age range 13-18 years) were enrolled in the study (24 right-handed AN-r in the early stages of the illness and treated in the same clinical setting and 24 age-matched healthy controls [HC]). High-resolution T1-weighted magnetic resonance images were acquired. Cerebral volumes, including the total amounts of gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were obtained with the Statistical Parametric Mapping software (SPM8); specific cortical regional volumes were computed by applying an atlas-based cortical parcellation to the SPM8 GM segments. Analysis of variance (ANOVA) was performed to identify any significant between-group differences in global and regional brain volumes. RESULTS: The analyses revealed reduced total GM volumes (p = 0.02) and increased CSF (p = 0.05) in AN-r, compared with HC. No significant between-group difference was found in WM volumes. At the regional level, significantly lower GM volumes in both frontal lobes (p = 0.006) and in the left insula (p = 0.016) were detected. No significant relationships were found between cerebral volumes and duration of illness, psychiatric comorbidities, psychopharmacological treatment, prepubertal phase, or presence of amenorrhea. CONCLUSIONS: The topographic distribution of GM reduction in a homogenous group of AN-r involves regions responsible for the emotional and cognitive deficits associated with the illness. These findings are discussed in relation to the roles of the insular cortex and the frontal lobes.

Transdiagnostic vs. disorder-focused perspective in children and adolescents with eating disorders: Findings from a large multisite exploratory study.

BACKGROUND: The transdiagnostic model of eating disorders (ED) proposes common cognitive mechanisms in patients with ED psychopathology. Little is known about their role in the maintenance of ED in children and adolescents. This study aimed to determine whether the relationships between key factors (low self-esteem, weight and shape control, clinical perfectionism, interpersonal problems, distress and mood instability) and core maintaining mechanisms (binge-eating and restraint) would support a transdiagnostic theory in young patients. METHODS: A total of 419 patients (mean age 14.7 ±â€¯2.14 years; age range: 7-18 years; males 13.8%) diagnosed with an ED were assessed in six Italian clinical centers in 2013. Multiple comparisons between ED diagnosis, correlation analysis and principal component analysis (PCA) were performed. RESULTS: Of the entire collective, 51.5% of patients were diagnosed with Anorexia Nervosa (AN), 12.3% were diagnosed with Bulimia Nervosa (BN) and 36.2% with Eating Disorder Not Otherwise Specified (EDNOS). In PCA, the core ED mechanisms, dietary restraint and binge eating, acted as poles of attraction of the other variables. The AN group was particularly linked to restraint and the BN group was particularly related to "Bulimia". Considering the diagnostic subtypes, there were no significant differences between the anorexic binge-purging group, bulimic purging group and bulimic non-purging group, which constituted a unique cluster related to affective, interpersonal problems and to perfectionism, indicating a very homogeneous subgroup. Restricting anorexic group (AN-R), related to shape concern and anxious-depressed mood, was not linked to the other subtypes. EDNOS appeared to be opposed to the AN-R group; the binge eating disorder group appeared to be independent from others. CONCLUSION: Our results suggest the presence of both specific and transdiagnostic mechanisms in ED subtypes, whose knowledge is of relevance for clinical practice.

[Anorexia nervosa and hyperactivity in adolescence: psychiatric and internal medicine features]. / Anoressia nervosa e iperattività in adolescenza: correlati psichiatrici e internistici.

AIM: The aim of the present study was to verify the influence of hyperactivity on internistic and psychiatric parameters in early onset anorexia nervosa restricting type (ANR). METHODS: Seventy-three adolescent females (mean age 13.5 years, SD: 2.27) with a diagnosis of ANR (DSM-IV-TR) were consecutively enrolled in the Child and Adolescent Eating Disorders Unit of the IRCCS-Stella Maris and assessed by an extensive clinical protocol. All patients completed: psychiatric evaluation for description of the DCA and comorbidities; pediatric assessment including complete auxological data, blood pressure, heart rate and other electro/echo cardiographic and biohumoral parameters. The hyperactivity was estimated by the application of the "Structured Interview for Anorexic and Bulimic Disorder-Expert Form" (Item 40) in the context of clinical observation. Subjects were identified according to their level of hyperactive (ANR+H) and non-hyperactive (ANR-H) activity. RESULTS: In the ANR+H group heart rate, leptin, sodium, potassium and gamma plasma proteins significantly differ compared to the group ANR-H. Patients with hyperactivity also have a complete form of ANR in 94% of cases compared with 66.7% of non-hyperactive; significant differences were found also in thought and attention CBCL and YSR subscales, combined with major internalizing problems. CONCLUSION: This study provides preliminary data which can orient research towards the development of specific treatments for the hyperactivity, in order to improve the prognosis and thus avoid the chronicity of the disorder and the development of complications in adult life.

[Regulatory disorders: a follow-up study]. / I disturbi della regolazione: uno studio di follow-up.

AIM: The self-regulation systems develop during early childhood resulting from the meeting of the constitutional characteristics of the child, his/her adaptability and environmental responses. The failure of the intersection of these dimensions leads to the onset of symptoms that can seriously affect the child's behavior and his/her relationship. Regulatory disorders of sensory processes (DR) were identified as independent nosographic category in the "Diagnostic Classification 0-3". The aim of this study was the description of the clinical features of a group of children for whom a diagnosis of regulatory disorders was made before the three years, and their development at school age. METHODS: The sample was composed of 28 children, 22 males and 6 females, selected from a group of 60 children, with a mean age at T0 of 34.8 months (range 14-56 months). The clinical reassessment was conducted after five years (T1), with a children's mean age of 103.5 months (range 71-150 months). RESULTS: Approximately 40% of school age participants shows no longer any disturbance, while the remaining % shows a very heterogeneous spectrum of disorders. CONCLUSION: The diagnosis of DR is sensitive enough to detect in infancy a wide range of developmental difficulties, but it is quite specific and relatively predictive about the child's subsequent development. Retrospectively the entire diagnostic profile provides more information than the primary diagnosis and the greatest impairment of the different dimensions explored predicts a more severe evolution.

General movements in infants with autism spectrum disorders.

General movements (GMs) are a distinct movement pattern carried out spontaneously without external stimulation and seen in fetuses of 9 weeks gestational age till 21 weeks postterm. GMs are helpful in the early diagnosis of an impaired central nervous system and the specific prediction of later neurological deficits. Autism spectrum disorder (ASD) is a neurodevelopmental disorder involving a life-long deficit in several aspects of the social and communicative behavior. Recently there appeared studies proving that children with ASD demonstrate disorders of motor development. To detect whether abnormalities in spontaneous motor activity can be observed already in the first months of life in infants with ASD. A retrospective study was performed by analyzing the family videos provided by parents of 20 children (male 17, female 3) later diagnosed as ASD. Home videos provided by parents of a control group of healthy children (n=20; male 10, female 10) matched for age with the ASD subjects and recorded in similar conditions were also analysed. In total 70 sequences were studied. Two independent observers, blind of the infants' outcome (ASD or normal), assessed the cases applying a global and a more detailed assessment of GMs. Hence, the age-specific GM pattern (normal or abnormal) as well as motor optimality scores were determined for each video sequence. Cohen kappa was 0.614. During the writhing movement period 70.0% sequences of infants with ASD showed poor repertoire GMs. In the control group, poor repertoire GMs were only seen in 12.5% of the sequences. In the fidgety movement period 20.8% of sequences were assessed as absent fidgety movements, 29.2% as abnormal fidgety movements. The large majority of the videos for the control cases were scored as normal (88.9%), 11.1% had no fidgety movements. According to the Mann-Whitney U test there were significant differences between the ASD and the control groups' optimality scores. The optimality scores were lower in the ASD group. The reduced optimality scores were mainly due to a lack of variable sequences, amplitude and speed of writhing GMs and an altered quality of fidgety and other spontaneous movements in the ASD group. Infants with ASD had more often poor repertoire writhing GMs as well as abnormal or absent fidgety movements than control infants. These data encourage further studies involving a larger number of family videos.

A view to regressive autism through home movies. Is early development really normal?

OBJECTIVE: To describe early development of children with regressive autism. METHOD: Home movies from the first 18 months of life of three groups of children with early onset autism (EOA), regressive autism (RA) and typical development (TD) were rated through the Grid for Attention in Infants in three age ranges. Different ANOVA and post hoc-tests were conducted on frequencies of behaviours. RESULTS: Differently from TD, for both RA and EOA non-social attention is higher than social attention across ages. While EOA is characterized by an early deficit in social attention, in RA social attention increases until the first birthday when its decrease proceeds at the same rate as the increase of non-social attention. CONCLUSION: We hypothesize that the intense interest towards objects can be the first sign of an atypical development also in RA; this distinguishing feature lead us to believe that regression, based on the assumption of a previous normal development, is only apparent.

Course of autism signs in the first year of life.

Autism spectrum disorders (ASD) are thought to be present right from birth, even if a minority of children displays a normal course during infancy followed by a regression during the second year of life. However, established criteria are not yet available to differentiate these different courses of ASD, and data coming from different sources have not yet been organized into a clear definition. The aim of this study was to elucidate the time of onset, as well as type, frequency and stability of symptoms during the first year of life in ASD. The behavioral summarized evaluation scale, applied to 40 home movies of children later diagnosed as having ASD, showed that most of the subjects (87.5%) display symptoms within the first year of life, when only a small group (12.5%) is completely symptom free. A group of more rated symptoms was found, constituting a typical pattern characterized by being withdrawn, and displaying poor social initiative, hypoactivity, and lack of emotional modulation. The importance of these findings is discussed in relation to early diagnosis and treatment.

Influence of parenteral nutrition on postoperative recovery in an experimental model of peritonitis.

BACKGROUND AND AIMS: There seems to be no clear-cut indications for routine TPN support after major elective surgery. The present study was designed to investigate whether TPN could improve the results of standard surgical care for acute peritonitis (laparotomy plus antibiotics). ANIMALS AND METHODS: Peritonitis was induced in 48 New Zealand rabbits (day -2). On day 0, appendectomy and peritoneal lavage were performed, ceftriaxone (250 mg, i.m./24 h.) was started and animals were randomly assigned to receive regular fluids (RF), glucose-based TPN (G-TPN) or isocaloric fat-based TPN (F-TPN) for 6 days. MAIN OUTCOME MEASURES: Balance studies (days 1-3), s-albumin, thyroid hormones and urinary catecholamines were determined at various points of the experiment. At postmortem, wound infection, residual intra-abdominal infection and laparotomy wound breaking strength were recorded. RESULTS: Peritonitis produced a fall in weight, s-albumin and T3. At day 6, weight-loss was more pronounced in RF than in G-TPN or F-TPN (-7 vs 1.5 vs -1.2%;P=0.0001) but s-albumin and T3 concentrations were similar. Diuresis (377 vs 268 vs 269 mL/3 days; P=0.01) was higher and water balance lower (373 vs 511 vs 480 mL/3 days; P=0.01) in Group RF. Although the differences were not statistically significant (P<0.2), persistent infection and wound breaking strength were slightly worse in the pooled TPN groups compared with the RF group (19 vs 6% and 542 vs 701 g, respectively). CONCLUSIONS: TPN failed to improve relevant biochemical markers and clinical outcome after laparotomy for peritonitis.

Early behavioral development in autistic children: the first 2 years of life through home movies.

OBJECTIVE: The main aim of the research is to study the early behavioral development in autistic children through home movies. METHODS: fifteen home movies, regarding the first 2 years of life of autistic children are compared with the home movies of 15 normal children. The films of the two groups were mixed and rated by blind ratings with the Grid for the Assessment of Normal Behavior in Infants and Toddlers. The grid is composed of 17 items grouped into three developmental areas: social competence, intersubjectivity and symbolic activity. For every area, we have identified specific children's behaviors. RESULTS: Significant differences between the two groups are found both in the range of age 0-6 for intersubjectivity, and in the ranges of age 6-12 and 18-24 for symbolic activity. CONCLUSIONS: The authors pose some hypotheses about an early-appearing impairment of intersubjectivity, the ability to represent other's state of mind, in subjects with autistic disorder.

Study of the onset of autism through home movies.

The authors describe the natural history and the beginning of pervasive developmental disorders (PDD) by the observation of home movies. The sample is composed of 26 children aged 18 months to 5 or 6 years at the first consultation. The methodology used in the observation of home movies includes: (1) application of the ERC-A-III scale for recognizing the precocious symptoms of autism; (2) analysis of the coming out and coming off of social, emotional and cognitive competences. The authors, starting from the analysis of these data, describe three kinds of onset and courses of PDD: progressive, regressive and fluctuating. The authors present some conclusive considerations on the different age of PDD onset in home movies, in anamnestic reconstruction and in recall for diagnosis.

Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation.

BACKGROUND: Emergency operation in the elderly carries a high risk of death. We investigated the incidence of euthyroid sick syndrome (ESS) and associated nutritional and endocrine abnormalities and their relationship to postoperative outcome in this population. METHODS: Sixty-six patients older than 70 years of age requiring emergency operations were assessed before any therapeutic intervention. Values for thyroid hormones, catecholamines, cortisol, interleukin-6, interleukin-1, C-reactive protein, and the Acute Physiology and Chronic Health Evaluation II score were determined. Nutritional assessment was carried out. Mortality rates and duration of hospital stay were related to ESS and albumin concentrations. RESULTS: ESS was diagnosed in 34 patients (51.50%) and was associated with worse Acute Physiology and Chronic Health Evaluation II scores (10.9 vs 8.6; p = 0.004), hypoalbuminemia (34.7 vs 40.8 gm/L; p = 0.0001), lower triceps skinfold (11.8 vs 14.6 mm; p = 0.03), and higher cortisol and norepinephrine levels (937 vs 741 nmol/L [p = 0.04] and 358 vs 250 pg/ml [p = 0.02], respectively), interleukin-6 plasma concentrations (347 vs 113 pg/ml; p = 0.01), death rate (20% vs 0%; p = 0.02), and length of hospital stay (17.2 vs 11.8 days; p = 0.03). A serum albumin level less than 35 gm/L was virtually always associated with ESS. CONCLUSIONS: ESS is highly prevalent in the elderly with acute surgical problems and is associated with poor nutrition, higher sympathetic response, and worse postoperative outcome. The serum albumin level at admission is a specific marker of ESS.

[Symptomatological patterns of infancy diseases. Presentation of a new Symptom Checklist]. / Pattern sintomatologici nei disturbi della prima infanzia. Presentazione di una nuova Symptom Checklist.

BACKGROUND: Recently it is often very frequent a request of specialist consultation for children with psychic discomfort expressed through somatic complaints and/or behavior disorders. The real meaning of these symptoms in terms of prognosis, is not clear; indeed they can be the first signs of a poor prognosis of developmental disorders or a transient developmental crisis. The objective of this study is the evaluation of a Symptom Checklist as an instrument which allows to point out the somatic complaints and the behavior disorders of Italian children aged less than 48 months and to identify symptoms patterns which label the main neurological and psychiatric diseases in that age. METHODS: The Symptom Checklist has been used transversely in a clinical sample of 30 subjects (24 males and 6 females) aged less than 48 months with developmental linguistic disorder, born prematurely or with a developmental pervasive disorder and in a control sample of 37 children (21 males and 16 females). RESULTS AND CONCLUSIONS: The results obtained, matching every single group to each other and every single group to the control group, identify symptoms pattern (somatic or behavioral) specific for each clinical condition examined; therefore, the clinical utility of Symptom Checklist in pointing out in infancy psychiatric risk cases for a poor prognosis is confirmed.

Prevention of catheter sepsis: the hub.

The prevention of catheter sepsis lies in a sound understanding of the routes through which catheters get contaminated. The catheter hub has been recognized as a portal for microorganisms causing catheter sepsis, particularly in central venous catheters inserted for > 1 wk. Bacteria and fungi may reach the internal surface of the catheter connector during manipulation by hospital staff and then colonize the entire lumen of the catheter. Endoluminal contamination has diagnostic, therapeutic, and preventive implications. Some traditional preventive approaches (site care, subcutaneous cuffs and tunnels, maximal aseptic barriers at the time of catheter insertion, and external antiseptic or antibiotic coating) may fail because they focus solely on the skin as a source of bacteria. Hub-related catheter sepsis can be prevented by aseptic hub manipulation, appropriate junction protection, and by reducing the number of catheter lumens, side ports, three-way stopcocks, and changes of the infusion sets. Needleless systems must be evaluated in terms of their safety in preventing endoluminal contamination. A new disinfecting catheter hub incorporating an antiseptic barrier has been developed and reduced hub-related catheter sepsis by more than 90%. The endoluminal route of intravascular catheter contamination must be taken into account when designing strategies for the diagnosis and prevention of catheter-related sepsis.

[Cognitive and affective characteristics of children with malformation syndrome]. / Considerazioni sulle caratteristiche cognitive e affettive del bambino con sindrome malformativa.

The aim of this paper is to study the psychological and relational aspects in children suffering from specific malformative syndrome and precisely Down s., Sotos s., X-Fragile s. and Williams s. Indeed literature provides much data related to the phenotype, to the organic-biological characteristics, but little or nothing is known about the affective structure, the episodes and to the particular dynamics that emerge in he relation between the parents and the malformed child. A protocol was applied to our sample group (16 subjects). This protocol includes laboratory and instrumental tests (chromosome test, neurometabolic screening, EEG, CT or cranial MRI, cardiac and abdominal ultrasonography, ear and eye test) aspects. This evaluation is carried out through the proposal of standardized situations (psychometric tests) and a use of a freer observational setting. This permits us to understand how the child perceives himself the awareness and the image he has of himself and how able he is to integrate his illness experiences and his way of relating with the environment. The data of our observations are thus used to compile a grill for the structural diagnosis of the personality. Besides, this evaluation is flanked by the observation of the family in order to explore the psychological image that parents have of their child, his character, his good points, his bad points, his similarities, how he relates to them, any educational problems and the emotional reaction that the communication of the diagnosis has raised in them. The videotaped observations are subsequently evaluated through the application of a grill for the study of the mother-child relationship. The results obtained from the psychological research underline a reasonable heterogeneity both of the intellectual level and of the metapsychological profile. Twelve subjects were mentally retarded (5 with mild mental retardation, 7 with moderate mental retardation); the remaining 4 had a normal cognitive development (3 with Sotos s., 1 with Williams s.). Psychological disturbances are present and thus divided: light disturbances (affective immaturity, neurotic-depressive organisation) in 11 subjects. Average disturbances (dysharmonious structure, and borderline personality) in 4 subjects; severe disturbances (psychosis) in 1 subject. Besides, above all in the group of subjects with X-Fragile s. and Down s., the tendency to assume behaviour of a regressive type, also postural, emerges. Among the 4 groups it is frequent to resort to defence mechanisms of hypomaniac type, accompanied by the denial of the patient's "sick parts". Another common characteristic concerns the quality of imaginary life which is shown to be repetitive and stereotype in content. Indeed these children's play activity characterized by a limited capacity of symbolization. Instead, when the symbolic process is more developed, contents concerning a deteriorated and destructive image of the Self emerges. Through the evaluation of family dynamics what is more noticeable is that the parent-malformed child interaction appears to be quite nonstimulating and noninvolving or incoherent, lacking in harmony and empathy towards the child's inner world. Indeed we can notice a lack of both verbal and extraverbal exchange of communication and brief interactive sequences which do not usually take into account the child's proposals and an affective tonality of depressive and nonaffective type. Therefore it may be concluded a certain smoothness in the clinical expression of the syndromes considered, both as far as the cognitive deficit entity and the psychic problems are concerned. Referring to the interactive dynamics between parents and children with dismorphic syndrom it seems that the child's pathology becomes the organizational summit of the above-mentioned relational dynamics among most of the patients examined...