Reasons and pathways of first-time consultations at child and adolescent mental health services in Italy: an observational study.

BACKGROUND: An increasing number of young people have made contact with the Child and Adolescent Mental Health Services (CAMHS). However, only a small proportion of the population with emotional problems, actually seek specialized care. Research concerning the help-seeking process and pathways to care of a clinical sample could help to develop effective health policies to facilitate access to specialized care. AIM: To analyze the access pattern for CAMHS, reasons of contact and care pathways of a consecutive sample of first-time patients. Our aim was to analyze the association between source of referral, socio-demographic and clinical variables. METHODS: Standardized assessment instruments and information concerning access patterns and care pathways were collected from 399 patients at first-time contact with CAMHS in a Northern Italian Region. RESULTS: Most patients were referred to CAMHS by school teachers (36 %) or health professionals (32 %), while only 17 % of the parents sought help by themselves. School issues (50 %) and emotional problems (17 %) were the most frequent reasons for contact. The proportion of first-time contacts with no diagnosis of mental disorder at their first consultation did not differ by source of referral. Parents of children who did not receive a clinical diagnosis of mental disorders described them as "psychosocially impaired" and their condition as "clinically severe" likewise parents of patients who received a psychiatric diagnosis. Patients with externalizing problems were more frequently referred by the parents themselves, while youth with internalizing problems were more often referred through health professionals. Families with non-traditional structures (adoptive, foster care, mono-parental) were more likely to consult CAMHS directly, while immigrant youth were more often referred by teachers. CONCLUSION: Socio-demographic and clinical characteristics can affect pathways to care. To improve early access to care for children and adolescents with ongoing mental disorders, a plan for proper action addressed to teachers and health professionals may well be important. This would improve their ability to recognize emotional and behavioral problems and use proper referral pathways, while informative intervention addressed to non-Italian families should inform them about the functioning and the mission of CAMHS.

Serum brain-derived neurotrophic factor (BDNF) levels in attention deficit-hyperactivity disorder (ADHD).

It has been proposed that the neurotrophin brain-derived neurotrophic factor (BDNF) may be involved in attention deficit-hyperactivity disorder (ADHD) etiopathogenesis. Alterations in BDNF serum levels have been observed in childhood/adulthood neurodevelopmental pathologies, but no evidence is available for BDNF serum concentrations in ADHD. The study includes 45 drug-naïve ADHD children and 45 age-sex matched healthy subjects. Concentration of serum BDNF was determined by the ELISA method. BDNF serum levels in patients with ADHD were not different from those of controls (mean ± SD; ADHD: 39.33 ± 10.41 ng/ml; controls: 38.82 ± 8.29 ng/ml, t = -0.26, p = 0.80). Our findings indicate no alteration of serum BDNF levels in untreated patients with ADHD. A further stratification for cognitive, neuropsychological and psychopathological assessment in a larger sample could be useful to clarify the role of BDNF in the endophenotype characterization of ADHD.

Improving upper limb motor functions through action observation treatment: a pilot study in children with cerebral palsy.

AIM: The aim of this randomized controlled trial was to assess whether action observation treatment may improve upper limb motor functions in children with cerebral palsy (CP). METHOD: All children with CP admitted to our unit for rehabilitation from May 2009 to May 2010 were eligible. Inclusion criteria were age between 6 years and 11 years, an IQ of at least 70, and no major visual and/or auditory deficits. Fifteen children were enrolled and randomly assigned to either a case group (n=8; four males, four females; median age 7 y 6 mo) or control group (n=7; five males, two females; median age 8 y). Six participants had left-sided hemiplegia, six right-sided hemiplegia, and three had tetraplegia; 10 were independent walkers. Those in the case group were asked to observe video clips showing daily age-appropriate actions, and afterwards to imitate them. Participants in the control group were asked to observe video clips with no motor content and afterwards to execute the same actions as cases. The primary outcome measure was the Melbourne Assessment Scale. Children were scored twice at baseline (2 wks apart), and at the end of treatment, by a physician blind to group assignment. RESULTS: At baseline groups did not differ on functional evaluation. After treatment, the functional score gain (Δ) was significantly different in the case and control groups (p=0.026). INTERPRETATION: The present results support the notion that action observation treatment can be an effective part of the rehabilitation programme in children with CP.

SD-OCT imaging of idiopathic macular holes with spontaneous closure.

Spectral-domain optical coherence tomography serial changes in three cases of spontaneous closure of idiopathic macular hole at stages II, III, and IV are described. Initial and serial spectral-domain optical coherence tomography images document the progressive closure. Macular holes apparently resolved spontaneously through two different mechanisms: posterior hyaloid detachment in case 1 and a contraction of epiretinal macular membrane in cases 2 and 3. The spontaneous closure of idiopathic full-thickness macular holes may occur in any stage of idiopathic macular hole; the small size of the hole is a common feature in all cases of spontaneous closure reported.

Intralesional interferon-α for conjunctival mucosa-associated lymphoid tissue lymphoma: long-term results.

OBJECTIVE: To report the long-term therapeutic results for patients with conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma who were treated with intralesional injections of interferon-α (IFN-α). DESIGN: Prospective, nonrandomized, interventional case series. PARTICIPANTS: Twenty eyes of 16 patients with histologically proven conjunctival MALT lymphoma in the absence of systemic disease. METHODS: Patients were given 1,500,000 international units (IU) of IFN-α (Roferon-A; Roche s.p.a., Milano, Italy) subconjunctivally inside the lesion 3 times weekly for 4 weeks. If there was even a minimal response, a further cycle of 1,000,000 IU 3 times weekly for 4 weeks was administered. MAIN OUTCOME MEASURES: Patients were followed up clinically using slit-lamp examination to determine evidence of tumor disappearance or recurrence. In 10 eyes, an incisional biopsy was performed 6 months after therapy to verify the histologic absence of the lesion. RESULTS: A complete response was obtained in 15 eyes (75%) at the end of first cycle treatment, and in 5 eyes (25%) after further cycles. Seventeen eyes (85%) showed no local recurrence after a median follow-up of 65 months (range, 15-136 months). Three eyes (15%) demonstrated recurrence at variable points after treatment. One patient with stage IIA lymphoma exhibited systemic lymphoma progression. CONCLUSIONS: Local immunotherapy with IFN-α seems to be an effective and lasting treatment method and provides an alternative to radiotherapy for conjunctival MALT lymphomas. Very few transient side effects were detected.

Lymphoepithelioma-like carcinoma involving the lacrimal gland and infiltrating the eyelids.

PURPOSE: To report a case of a lymphoepithelioma-like carcinoma (LELC), which is a variant of carcinoma most commonly involving the nasopharynx and rarely occurring in a variety of sites outside its typical location. METHODS: We present the case of a 79-year-old Caucasian man with LELC of the lacrimal gland undergoing surgical resection of the mass. RESULTS: The patient had remained disease-free for 2 years, and then he developed homolateral metastases in latero-cervical and parotid lymph nodes, detected by computed tomography and confirmed by fine-needle aspiration biopsy. He did not receive any surgical treatment, radiotherapy, or chemotherapy because of the advanced stage of the disease and poor health condition. CONCLUSIONS: This case report suggests that a diagnosis of lacrimal gland LELC makes combined early and radical therapy necessary.

Patterns of prescription of antiepileptic drugs in patients with refractory epilepsy at tertiary referral centres in Italy.

PURPOSE: To evaluate the pattern of prescription of antiepileptic drugs (AEDs) and other medications in a representative population of patients with refractory epilepsy attending tertiary referral centres in Italy. METHODS: Descriptive analysis of data obtained at baseline from 933 adults and 191 children with refractory epilepsy enrolled consecutively in an observational study at 11 tertiary referral centres in Italy. Multivariate logistic regression analysis was used to assess predictors of utilization of the most commonly prescribed AEDs. RESULTS: Polytherapy was used in 79% of adults and 75% of children, with over one-third of adults and children being prescribed ≥3 AEDs. In adults, the most commonly used AEDs were levetiracetam (35%), carbamazepine (34%) and lamotrigine (30%). In children, valproic acid was by far the most commonly used AED (46%), followed by carbamazepine (27%), topiramate (21%), and phenobarbital (20%). The most common AED in partial epilepsy was carbamazepine (331 out of 893 patients, 37%), followed by levetiracetam (33%) and lamotrigine (26%). In generalized or undetermined epilepsies, the AEDs most commonly used were valproic acid (139 out of 223 patients, 62%), lamotrigine (33%) and levetiracetam (28%). Second generation AEDs were prescribed in 81% of adults and 54% of children. Comedications used for indications other than epilepsy were used by 32% of adults and 17% of children. CONCLUSIONS: Prescription patterns were consistent with current evidence about the spectrum of efficacy of individual AEDs in different epilepsy syndromes. The high prevalence of polytherapy, including combinations of three or more AEDs, is a cause for concern.

Photodynamic therapy with verteporfin for symptomatic circumscribed choroidal hemangioma: five-year outcomes.

OBJECTIVE: To evaluate the long-term efficacy of verteporfin photodynamic therapy (PDT) as the primary treatment for symptomatic circumscribed choroidal hemangioma (CCH). DESIGN: Prospective consecutive, 2-centered, noncomparative, interventional case series. PARTICIPANTS: Twenty-five subjects with symptomatic CCH. All patients had recent onset of visual symptoms and evidence of exudative macular changes on fluorescein angiography (FA) and optical coherence tomography (OCT). METHODS: Verteporfin 6 mg/m(2) body surface area was administered intravenously over a 10-minute interval. Five minutes after infusion, a 689 nm laser was applied with a light dose of 50 J/cm(2) for the first 3 patients and a light dose of 100 J/cm(2) for all the other patients. Retreatments were performed in case of persistent exudation found on OCT. Evaluation of best-corrected visual acuity (BCVA) using Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria, FA, indocyanine green angiography (ICGA), OCT, and ultrasound were performed before PDT and on follow-up examinations. All patients were followed for at least 5 years. MAIN OUTCOME MEASURES: Primary outcome measures were changes in BCVA and foveal center thickness (FCT) between baseline and month 60. Secondary measures were tumor thickness decrease, absence of leakage on FA, and adverse events. RESULTS: Twenty-two patients received 1 PDT session at 100 J/cm(2), and no recurrences were detected. Three eyes, treated with 50 J/cm(2), received a second PDT session at 100 J/cm(2) 1 month after the first session. After a follow-up of 60 months, BCVA improved an average of 18.5 ETDRS letters (P<0.001); BCVA improved by > or =2 lines in 19 eyes (76%). The FCT decreased from a mean of 386.20 microm to 179.2 microm, and OCT showed the complete resolution of macular exudation in all cases. All tumors responded with a reduction in size. No treatment-related adverse events or complications were identified. CONCLUSIONS: The 5-year results of PDT in treating symptomatic CCH support treatment with a light dose of 100 J/cm(2) after slow intravenous infusion of verteporfin to stabilize or improve visual acuity and resolution of macular exudation.

Macular functional changes evaluated with MP-1 microperimetry after intravitreal bevacizumab for subfoveal myopic choroidal neovascularization: one-year results.

PURPOSE: The purpose of this study was to evaluate 1-year functional and structural effects of intravitreal bevacizumab for subfoveal choroidal neovascularization secondary to pathologic myopia (myopic choroidal neovascularization). METHODS: Fifteen eyes with myopic choroidal neovascularization participated in this prospective interventional, noncomparative case series. All patients were treated with one intravitreal injection of 1.25 mg bevacizumab. Retreatments were performed in case of persistent or recurrent leakage on fluorescein angiography and/or intraretinal fluid on optical coherence tomography. Evaluation of best-corrected visual acuity using Early Treatment of Diabetic Retinopathy Study criteria, MP-1 microperimetry, optical coherence tomography, and fluorescein angiography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment. RESULTS: After a follow-up of 12 months, best-corrected visual acuity improved on average of 0.23 logarithm of the minimum angle of resolution. Mean macular sensitivity within the central 8 degrees increased on average of 2.62 dB at 12-month postinjection. The mean number of measurement points within the central absolute scotoma reduced significantly from 12.47 before treatment to 6.27 at 1-year follow-up. An improvement of fixation stability from baseline was observed in 9 patients (60%). No treatment adverse events were evidenced. CONCLUSION: Improvement of macular sensitivity and fixation stability 1 year after intravitreal bevacizumab for myopic choroidal neovascularization suggest a stable and progressive macular function recovery. The mean treatment session was 1.53, with 53.3% of patients needing only a single intravitreal bevacizumab injection, supporting a potential long-lasting efficacy of intravitreal bevacizumab treatment.

Photodynamic therapy for vasoproliferative retinal tumors.

PURPOSE: To report our experience with photodynamic therapy (PDT) with verteporfin for patients with vasoproliferative retinal tumors (VPRTs). METHODS: Three patients with VPRTs who presented with macular exudative changes were treated with one session of PDT with 6 mg/m body surface area of verteporfin and a light dose of 100 J/cm at 689 nm delivered in 166 seconds. Biomicroscopy, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and ultrasonography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment; visual acuity was measured using Early Treatment Diabetic Retinopathy Study criteria. RESULTS: At the 1-year follow-up, all tumors responded with a reduction in size (mean height: pretreatment, 2.96 mm; posttreatment, 1.32 mm), and optical coherence tomography showed complete resolution of macular exudates. For all patients, fluorescein angiography evidenced reduction of leakage from the lesion, and indocyanine green angiography verified nonperfusion of the vascular channels. An improvement in visual acuity (average, 4.7 Early Treatment Diabetic Retinopathy Study letters) was observed. No retreatment was needed. CONCLUSION: PDT may represent an effective and safe modality of treatment for VPRTs because of its selectivity. Our study supports the application of a light dose of 100 J/cm, although further studies with larger numbers of cases and longer follow-ups are required.

Choroidal neovascularization after laser-assisted in situ keratomileusis following penetrating keratoplasty.

PURPOSE: To describe a case of choroidal neovascularization (CNV) after laser in situ keratomileusis (LASIK) following penetrating keratoplasty (PK). METHODS: Case report. RESULTS: A 30-year-old man underwent PK in both eyes for bilateral keratoconus in 1997. Two years later, best-corrected visual acuity (BCVA) was 20/40 (-6=-4.50 x 170 degrees ) in RE and 20/20 (-1.50=-0.50 x 90 degrees ) in LE. To reduce the anisometropic defect, LASIK was performed in RE. After surgery, the refractive defect in RE reduced to -1.75 x 125 degrees and BCVA improved to 20/25. Six months after LASIK the patient presented loss of vision and metamorphopsia in RE due to choroidal neovascularization. BCVA was reduced to 20/200. Photodynamic therapy was performed in RE; 1 year later BCVA was stable at 20/200. CONCLUSION: Vitreoretinal complications after LASIK occur rarely. The potential relationship between CNV and LASIK is discussed.

Lack of SCN1A mutations in familial febrile seizures.

PURPOSE: Mutations in the voltage-gated sodium channel subunit gene SCN1A have been associated with febrile seizures (FSs) in autosomal dominant generalized epilepsy with febrile seizures plus (GEFS+) families and severe myoclonic epilepsy of infancy. The present study assessed the role of SCN1A in familial typical FSs. METHODS: FS families were selected throughout a collaborative study of the Italian League Against Epilepsy. For each index case, the entire coding region of SCN1A was screened by denaturant high-performance liquid chromatography. DNA fragments showing variant chromatograms were subsequently sequenced. RESULTS: Thirty-two FS families accounting for 91 affected individuals were ascertained. Mutational analysis detected a single coding variant (A3169G) on exon 16. The extended analysis of all family members and 78 normal controls demonstrated that A3169G did not contribute to the FS phenotype. CONCLUSIONS: Our study demonstrated that SCN1A is not frequently involved in common FSs and suggested the involvement of specific FS genes.