Childhood obesity: prevention and strategies of intervention. A systematic review of school-based interventions in primary schools.

PURPOSE: Two crucial aspects of obesity prevention are early childhood and school-based interventions. The main purpose of this systematic review wass to evaluate the efficacy and the feasibility of school-based interventions performed in primary schools. METHODS: All pertinent data from the literature have been critically examined and reviewed to evaluate the efficacy and the feasibility of different strategies of interventions. In particular, many studies have been performed in school-aged children. RESULTS: Data from literature suggest that educational interventions toward healthy eating habits and physical activity at school could be a key strategy in the prevention of obesity, because it has been shown that is difficult to treat obesity in adults through changes in the lifestyle rather than during childhood. Recent advances in technology, especially web-based interventions, have been used to provide a specific content addressing healthy lifestyle with regard diet and exercise. These data suggest the opportunity to use web-interactive programs as a new challenging technique of communication in order to promote healthy behaviors. CONCLUSIONS: The early detection and treatment of obesity in children may be the best approach to prevent future increases in morbidity, as well as healthcare costs that will likely occur as overweight and obese children age.

Impact of a weight loss program on migraine in obese adolescents.

BACKGROUND AND PURPOSE: Increased headache frequency and severity have been observed in obese populations, but the real impact of a weight loss treatment on headache has not been studied. We investigated this issue in a sample of obese adolescents. METHODS: In all, 135 migraineurs, aged 14-18 years, with body mass index (BMI) ≥ 97 th percentile, participating in a 12-month-long program, were studied before and after treatment. The program included dietary education, specific physical training, and behavioral treatment. RESULTS: Decreases in weight (P < 0.01), BMI (P < 0.01), waist circumference (P < 0.01), headache frequency (P < 0.01) and intensity (P < 0.01), use of acute medications (P < 0.05), and disability (P < 0.05) were observed at the end of the first 6-month period and were maintained through the second 6 months. Both lower baseline BMI and excess change in BMI were significantly associated with better migraine outcomes 12 months after the intervention program. CONCLUSIONS: Significant improvements in both adiposity and headache data were observed in obese adolescents with migraine who participated in a 12-month-long interdisciplinary intervention program for weight loss. Initial body weight and amount of weight loss may be useful for clinicians to predict migraine outcomes.

Early-onset absence epilepsy: SLC2A1 gene analysis and treatment evolution.

BACKGROUND AND PURPOSES: To determine the prevalence of SLC2A1 mutations in children with early-onset absence epilepsy (EOAE) and to investigate whether there were differences in demographic and electroclinical data between patients who became seizure-free with anti-epileptic drug (AED) monotherapy (group I) and those who needed add-on treatment of a second AED (group II). METHODS: We reviewed children with EOAE attending different Italian epilepsy centers. All participants had onset of absence seizures within the first 3 years of life but otherwise conformed to a strict definition of childhood absence epilepsy. Mutation analysis of SLC2A1 was performed in each patient. RESULTS: Eighty-four children (57 in group I, 27 in group II) fulfilled the inclusion criteria. No mutation in SLC2A1 was found. There were no statistical differences between the two groups with regard to F/M ratio, age at onset of EOAE, early history of febrile seizures, first-degree family history for genetic generalized epilepsy, duration of AED therapy at 3 years after enrollment, use of AEDs at 3 years, failed withdrawals at 3 years, terminal remission of EOAE at 3 years, and 6-month follow-up EEG data. Mean duration of seizures/active epilepsy was significantly shorter in group I than in group II (P = 0.008). CONCLUSIONS: We demonstrate that in a large series of children with rigorous diagnosis of EOAE, no mutations in SLC2A1 gene are detected. Except for duration of seizures/active epilepsy, no significant differences in demographic and electroclinical aspects are observed between children with EOAE who responded well to AED monotherapy and those who became seizure-free with add-on treatment of a second AED.

Effects of the abrupt switch from solution to modified-release granule formulation of valproate.

BACKGROUND: A new modified-release (MR) granule formulation of valproate (VPA) has been recently developed for the treatment of children with epilepsy. It consists of tasteless microspheres that can be sprinkled on soft foods and easily swallowed. There are no data on the effectiveness of this formulation in pediatric age. AIM OF THE STUDY: To evaluate the effects of the abrupt switch from solution to VPA MR granules in children undergoing chronic treatment. METHODS: We enrolled children receiving VPA solution as sole or adjunctive therapy and switched them to MR granules at identical dosages. VPA blood level, treatment efficacy (clinical and EEG data), tolerability (adverse reactions), palatability, ease of administration, and compliance were evaluated before switching (T0) and after 4 weeks (T1). RESULTS: Out of 112 enrolled children, 108 (96.4%) completed the evaluation. We observed no significant differences between the patients at T0 and T1 in VPA blood levels, treatment efficacy, tolerability, and compliance. MR granules were judged more palatable (P < 0.05) and easier to administer (P < 0.05) than solution by children and parents. At 6-month follow-up, all patients continued to use MR granules. CONCLUSION: Modified-release granule formulation of VPA may be a reliable alternative to solution for its convenience of use.

Cognitive and linguistic abnormalities in benign childhood epilepsy with centrotemporal spikes.

AIM: To assess the cognitive function and language ability in children with benign partial epilepsy with centrotemporal spikes. METHODS: Twenty-five patients with benign partial epilepsy with centrotemporal spikes were included. They were divided into two subgroups. Group I: 10 patients with rolandic focus who were not treated. Group II: 15 patients with rolandic focus receiving treatment. A third Group of 12 healthy subjects have been studied. All children underwent standardized neuropsychological testing: electroencephalogram recording, Wechsler Intelligence Scale for Children-revised, Peabody Picture Vocabulary Test-III (PPVT-III) and Boston Naming Test (BNT), both during active disease (T1) and 2 years after recovery from epilepsy (T2). RESULTS: At T1 evaluation, no significant differences in group I and II patients about general intelligence, when compared with controls, were found. Group I and II patients were impaired with respect to controls in the receptive and expressive vocabulary evaluated with PCVT-III and BNT, respectively. At T2 evaluation, group I and II patients showed a normalization of the language abnormalities. CONCLUSION: Deficits of speech-related abilities can be detected in children with this type of epilepsy: these dysfunctions seem to be independent of the effects of antiepileptic treatment and are reversible after remission of epilepsy.

A 12-month longitudinal study of calcium metabolism and bone turnover during valproate monotherapy.

BACKGROUND AND PURPOSE: Treatment with valproate (VPA) can cause changes in bone mineral metabolism, but the real influences and the underlying pathologic mechanisms are still unclear and under discussion. The aim of this study was to examine the changes on calcium metabolism and bone turnover in post-pubertal male patients with newly diagnosed idiopathic generalized epilepsy (IGE) before (baseline evaluation) and 12 months after VPA monotherapy (second evaluation). METHODS: Participants included 20 post-pubertal males with IGE, aged 16.5-22.1 years. Also 20 post-pubertal sex- and age-matched healthy controls were evaluated. Physical activity, calcium and vitamin D intake were determined. Laboratory samples were obtained to measure biochemical parameters of bone metabolism and bone turnover: serum calcium, phosphate, magnesium, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, intact parathyroid hormone, total alkaline phosphatase, bone alkaline phosphatase (bone-ALP), osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP). RESULTS: At baseline evaluation, there were no significant differences between controls and patients parameters. At second evaluation, patients showed both markers of bone formation and resorption significantly higher than baseline values (bone-ALP: 51.2 +/- 9.9 vs. 57.3 +/- 9.3 U/l, P < 0.01; OC: 8.1 +/- 1.1 vs. 10.4 +/- 1.5 microg/l, P < 0.01; PICP: 138.7 +/- 16.4 vs. 152.6 +/- 17.1 microg/l, P < 0.01; ICTP: 3.8 +/- 0.8 vs. 5.9 +/- 0.6 microg/l, P < 0.01). CONCLUSIONS: Valproate monotherapy in epileptic post-pubertal males causes a significant increase of bone turnover.

Response to high-energy photons of PTW31014 PinPoint ion chamber with a central aluminum electrode.

Since its introduction the PinPoint (PTW-Freiburg) micro-ionization chamber has been proposed for relative dosimetry (output factors, depth dose curves, and beam profiles) as well as for determination of absolute dose of small high-energy photon beams. This paper investigates the dosimetric performance of a new design (type 31014) of the PinPoint ion chamber with a central aluminum electrode. The study included characterization of inherent and radiation-induced leakage, ion collection efficiency and polarity effect, relative response of the chamber, measurement of beam profiles, and depth dose curves. The 6 and 15 MV photon beams of a Varian 2100 C/D were considered. At the nominal operating voltage of 400 V the PinPoint type 31014 chamber was found to present a strong field size dependence of the polarity correction factor and an excess of the collected charge, which can lead to an underestimation of the collection efficiency if determined with the conventional "two-voltage" method. In comparison to the original PinPoint design (type 31006) the authors found for type 31014 chamber no overresponse to large-area fields if polarity correction is applied. If no correction is taken into consideration, the authors found the chamber's output to be inaccurate for large-area fields (0.5% accuracy limited up to the 12 x 12 and 20 x 20 cm2 field for the 6 and 15 MV beams, respectively), which is a direct consequence of the stem and polarity effects due to the chamber's very small sensitive volume (0.015 cc) and cable irradiation. Beam profiles and depth dose curves measured with type 31014 PinPoint chamber for small and medium size fields were compared to data measured with a 0.125 cc ion chamber and with high-resolution Kodak EDR2 films. Analysis of the penumbra (80%-20% distance) showed that the spatial resolution of type 31014 PinPoint ion chamber approaches (penumbra broadening < or = 0.6 mm) EDR2 film results.

Dosimetric analysis of Tomotherapy-based intracranial stereotactic radiosurgery of brain metastasis.

PURPOSE: This paper analyzes Tomotherapy-based intracranial stereotactic radiosurgery (HTSRS) of brain metastasis targeting two end-points: 1) evaluation of dose homogeneity, conformity and gradient scores for single and multiple lesions and 2) assay of dosimetric criticality of completion of HTSRS procedures. METHODS: 42 treatment plans of 33 patients (53 brain lesions) treated with HTSRS were analyzed. Dose to healthy brain, homogeneity, conformity and gradient indexes were evaluated for each lesion. Influence of Field Length and multiple lesions cross-talk effect were assessed. Treatment interruption and completion was investigated using radiochromic films in order to examine the delivered dose and its robustness to patient intrafraction movement. RESULTS: The average dose homogeneity index was 1.04 ±â€¯0.02 (SD). Average dose conformity and gradient score indexes were 1.4 ±â€¯0.2 and 50 ±â€¯14 respectively. We found a strong correlation of the dose to healthy brain and conformity and gradient indexes with target(s) volume for which analytical functions were obtained. Field Length and cross-talk effect were significantly correlated with poor gradient scores, but were found not to affect dose conformity. CONCLUSIONS: Homogeneity and conformity of HTSRS plans achieved excellent scores, while dose falloff and dose to healthy brain were slightly larger when compared with non-coplanar SRS techniques. Care should be given if treating large (>3 cc) or multiple near in-plane lesions in order to reduce dose to healthy brain. Analysis of interrupted treatments suggests splitting HTSRS treatments in two consecutive fractions in order to prevent target miss and overdosage due to patient intrafraction movement.

Helical Tomotherapy of the breast: can thermoplastic immobilization improve the reproducibility of the treatment setup and the accuracy of the delivered dose?

PURPOSE: To evaluate the impact of thermoplastic mask immobilization in the setup reproducibility and delivered dose for Helical Tomotherapy (HT) of the breast/chest wall. METHODS: 16 patients treated with Accuray Hi-Art HT for breast-cancer were considered. Patients were positioned supine with arms extended above the head using Civco Wing Board (WB) system. In 50% of patients an Orfit thermoplastic mask was added in order to improve immobilization. Before each treatment fraction a megavoltage CT (MVCT) scan was taken and registered to the planning CT by experienced medical staff. The impact of thermoplastic mask was investigated analysing MVCT shift-roll data and MVCT dose distribution using Planned Adaptive software. RESULTS: In the analysed cases, the addition of thermoplastic mask had minor impact on the lateral, longitudinal and roll data distribution. Variance of vertical shifts was significantly reduced in the WB + Orfit group. Van Herk's margins were not affected by addition of thermoplastic immobilization. In both groups, target coverage (V95) and maximum dose (D1) were almost identical to planned values. D1 of organs at risk were not significantly different in the two groups. CONCLUSIONS: Analysis of shift-roll data shows no improvement in the group of patients immobilized with the addition of thermoplastic mask. Van Herk's margin is quite large (7-10 mm) in both groups evidencing the need to perform daily setup correction. The adapted dose distribution complies well with the planned one, showing that if MVCT is used before each treatment fraction, a 3 mm margin (setup component) for CTVs expansion could be adequate.

Migraine and obesity: metabolic parameters and response to a weight loss programme.

BACKGROUND AND OBJECTIVE: Weight loss can determine significant improvement of migraine in obese patients. Herein, we evaluated a clinical sample of adolescent migraineurs with obesity who participated in an interdisciplinary programme for weight loss, in order to identify possible metabolic parameters associated with good migraine control. SUBJECTS AND METHODS: Using a cross-sectional design, we evaluated 112 out of 135 adolescents who previously underwent our intervention programme. Based on persistence of headache, subjects for comparison were 40 migraine-free and 72 not migraine-free adolescents. Participants underwent anthropometric evaluations and biochemical tests. RESULTS: Patients with persistence of migraine had significantly higher weight (P < 0.01), body mass index (P < 0.01), waist circumference (P < 0.01), homeostasis model assessment of insulin resistance (P < 0.001), triglyceride (P < 0.05), total cholesterol (P < 0.05) and low-density lipoprotein cholesterol (P < 0.05) values when compared with those who became migraine-free. Between potential predictors, only insulin resistance (odds ratio = 3.5, 95% confidence interval = 1.4-6.1; P < 0.001) was significantly associated with persistence of migraine after intervention programme. CONCLUSIONS: Among obese adolescents with migraine who underwent an intervention programme for weight loss, patients who did not become migraine-free showed higher adiposity values than those who became migraine-free. Patients with insulin resistance had 3.5 times the odds of having persistence of migraine compared with those without.

A prototype 3D CT extension for radiotherapy simulators.

In this paper we present a report on our custom 3D CT extension capable of producing fully 3D tomographic studies from conventional radiotherapy simulator cone-beam fluoro output. The extension consists of a common PC system on which a proprietary software toolkit provides the appropriate environment for reconstruction and acquisition of cone-beam data provided by commercial simulator fluoro video chains. The extension may compare favorably with CT options offered by simulator manufacturers: in particular, multi-slice single-scan reconstruction seems to be achievable while the current commercial solutions are based on single-slice single-scan. Radiotherapy applications include on-line treatment planning, patient treatment verification and registration.

The use of complementary and alternative therapies for chronic pain following spinal cord injury: a pilot survey.

OBJECTIVE: The purpose of this study was to determine the patterns and reasons for the use of complementary and alternative medicine (CAM) as a treatment for chronic pain among individuals with spinal cord injuries (SCI). METHODS: Telephone surveys were conducted in a sample of 77 people with SCI and chronic pain. RESULTS: Of those surveyed, 40.3% had used at least one CAM technique to manage chronic pain. The most common reason was dissatisfaction with conventional medicine. Acupuncture was the most frequently used modality, followed by massage, chiropractic manipulation, and herbal medicine. Acupuncture was rated lowest for satisfaction with pain relief, and massage was rated highest. Individuals not using conventional pain medication or who desired greater control over their health care practices tended to use more CAM techniques than others. Income, insurance coverage, and duration of pain were related to use of CAM. In general, CAM methods were effective for some and totally ineffective for others, indicating selective utility in this population. CONCLUSIONS: Despite this small opportunistic sample, the prevalence of CAM among individuals with SCI appears similar to that in the general population. A placebo-controlled trial is needed to evaluate the efficacy of various therapies in the SCI population. The fact that the most effective therapy, massage, was not frequently used suggests the need for more awareness of and research into this technique.

An object oriented fully 3D tomography visual toolkit.

In this paper we present a modern object oriented component object model (COMM) C + + toolkit dedicated to fully 3D cone-beam tomography. The toolkit allows the display and visual manipulation of analytical phantoms, projection sets and volumetric data through a standard Windows graphical user interface. Data input/output is performed using proprietary file formats but import/export of industry standard file formats, including raw binary, Windows bitmap and AVI, ACR/NEMA DICOMM 3 and NCSA HDF is available. At the time of writing built-in implemented data manipulators include a basic phantom ray-tracer and a Matrox Genesis frame grabbing facility. A COMM plug-in interface is provided for user-defined custom backprojector algorithms: a simple Feldkamp ActiveX control, including source code, is provided as an example; our fast Feldkamp plug-in is also available.

Glut1 deficiency: when to suspect and how to diagnose?

Impaired glucose transport across the blood-brain barrier results in GLUT1 deficiency syndrome (GLUT1-DS), characterized by infantile seizures, developmental delay, acquired microcephaly, spasticity, ataxia, and hypoglycorrhachia. A part from this classic phenotype, clinical conditions associated with a deficiency of GLUT1 are highly variable and several atypical variants have been described; in particular, patients with movement disorders, but without seizures, with paroxysmal exertion-induced dyskinesia, have been reported. Most patients carry heterozygous de novo mutations in the GLUT1-gene but autosomal dominant and recessive transmission has been identified. Diagnosis is based on low cerebrospinal fluid glucose, in the absence of hypoglycemia, and it is confirmed by molecular analysis of the GLUT1-gene and by glucose uptake studies and immunoreactivity in human erythrocytes. Treatment with a ketogenic diet results in marked improvement of seizures and movement disorders. This review summarizes recent advances in understanding of GLUT1-DS and highlights the diagnostic and therapeutic approach to GLUT1-DS.

Antiepileptic drug withdrawal in childhood epilepsy: what are the risk factors associated with seizure relapse?

BACKGROUND: In recent years, several studies have been conducted to determine the risk of relapse after antiepileptic drug (AED) withdrawal: there is no general agreement on criteria that can predict safe discontinuation or seizure recurrence. AIMS: To evaluate prospectively the relapse rate of epilepsy associated to AED withdrawal in epileptic children and to determine the risk factors of seizure recurrence. METHODS: One hundred-sixty-eight children with epilepsy who were seizure-free for at least 2 years were enrolled and all children were proposed to stop AED treatment and were followed. In all children electroencephalograms (EEGs) were performed before the withdrawal of AEDs and after discontinuation of the treatment. RESULTS: A total of 48 (28.6%) children relapsed; half of these patients relapsed while reducing the AED dose and the other half after the AED was withdrawn; after 2 years without AEDs, the risk of relapse was very low. Data evaluated by multivariable analysis showed that the children receiving polytherapy before AED withdrawal, having a history of febrile seizures and suffering from multiple seizure types relapsed more frequently. The presence of abnormal post-withdrawal EEG recordings was associated with a higher risk of seizure recurrence. CONCLUSIONS: Epileptic children, after a seizure-free period of 2 years, have a low risk of seizure recurrence. The potential risk factors of relapse, are multiple seizure types previous polytherapy, history of febrile seizures and abnormalities in post-withdrawal EEG.

A two-step selection of breast cancer patients candidates for exclusive IORT with electrons: a mono-institutional experience.

AIM: To assess the impact of a two-step multiparameter selection on the actual enrollment of women with breast cancer into a prospective intraoperative radiotherapy (IORT) trial. PATIENTS AND METHODS: From September 2009, a prospective clinical trial was started in order to deliver adjuvant exclusive single -fraction IORT to patients with early breast cancer. To select patients meeting suitable eligibility criteria for the clinical trial, a two-step decision process was developed: at pre-surgical examination (first step) and during surgery (second step). RESULTS: A series of 464 patients with breast cancer was analysed: at the first step, out of 464 patients, 333 (71%) were considered eligible for the IORT protocol; at the second step, out of 333 patients, 199 (60%) met the eligibility criteria and received the IORT fraction according to the criteria of the controlled trial. CONCLUSION: In our experience, the ultimate rate of patients who enrolled in the IORT clinical trial after the two-step decision process was 43%.

Adjuvant androgen deprivation impacts late rectal toxicity after conformal radiotherapy of prostate carcinoma.

To evaluate whether androgen deprivation impacts late rectal toxicity in patients with localised prostate carcinoma treated with three-dimensional conformal radiotherapy. One hundred and eighty-two consecutive patients treated with 3DCRT between 1995 and 1999 at our Institution and with at least 12 months follow-up were analysed. three-dimensional conformal radiotherapy consisted in 70-76 Gy delivered with a conformal 3-field arrangement to the prostate+/-seminal vesicles. As part of treatment, 117 patients (64%) received neo-adjuvant and concomitant androgen deprivation while 88 (48.4%) patients were continued on androgen deprivation at the end of three-dimensional conformal radiotherapy as well. Late rectal toxicity was graded according to the RTOG morbidity scoring scale. Median follow up is 25.8 (range: 12-70.2 months). The 2-year actuarial likelihood of grade 2-4 rectal toxicity was 21.8+/-3.2%. A multivariate analysis identified the use of adjuvant androgen deprivation (P=0.0196) along with the dose to the posterior wall of the rectum on the central axis (P=0.0055) and the grade of acute rectal toxicity (P=0.0172) as independent predictors of grade 2-4 late rectal toxicity. The 2-year estimates of grade 2-4 late rectal toxicity for patients receiving or not adjuvant hormonal treatment were 30.3+/-5.2% and 14.1+/-3.8%, respectively. Rectal tolerance is reduced in presence of adjuvant androgen deprivation.

Is acupuncture effective in treating chronic pain after spinal cord injury?

OBJECTIVES: To evaluate the efficacy of acupuncture as a treatment for chronic pain and secondary symptoms after spinal cord injury (SCI) and to identify disease-specific variables associated with response to treatment. DESIGN: A within-subjects design consisting of a 7(1/2)-week no-acupuncture baseline period followed by a 7(1/2)-week treatment period and a follow-up assessment 3 months posttreatment. SETTING: Medical rehabilitation research center. PARTICIPANTS: Twenty-two people with SCI who experienced moderate to severe pain of at least 6 months' duration. INTERVENTION: A course of 15 acupuncture treatments was administered over a 7(1/2)-week period. MAIN OUTCOME MEASURES: Numeric Rating Scale of pain intensity; ratings of interference with activity, individualized symptom rating, Center for Epidemiologic Studies-Depression Scale; Speilberger State Trait Anxiety Inventory, and General Well-Being Schedule. RESULTS: Ten patients (46%) showed improvement in pain intensity and pain sequelae after treatment. However, 6 patients (27%) reported an increase in pain that was still present 3 months after treatment. CONCLUSIONS: About 50% of the study sample reported substantial pain relief after acupuncture treatment, suggesting that acupuncture may provide pain relief for at least a subgroup of individuals with SCI. Future research is needed to determine what part of this effect is because of acupuncture versus nonspecific effects such as placebo effects and regression to the mean.