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A new type of "speleothem" was recently found and described in submarine caves along the Southern coast of the Adriatic Sea in Italy. Previous studies demonstrated the fully biogenic and submarine origin of these structures which appeared to be formed by calcareous tubules of worms, embedded in a much finer texture matrix. AMS radiocarbon dating analyses allowed the determination of the age of these structures and to study the temporal evolution of their growth rate. In this paper, we report new dates obtained on the matrix around the already dated core tubules. Compositional analyses demonstrated that the matrix is mainly formed by calcium carbonate and AMS radiocarbon age measurements performed at CEDAD suggest its biogenic origin. Absolute ages on the matrix are statistically consistent internally and with the calcareous tubules. The obtained results are highly complementary to other studies being performed in order to identify the biological processes governing the formation and growth of these structures. [ABSTRACT FROM AUTHOR]

The rapid growth of built-up areas and infrastructure in the Mediterranean environment has resulted in the expansion of urban interfaces where fire can ignite and spread. Within this context, there is a need to understand spatial patterns of ignition distribution and the relative importance of influencing drivers. In response to this need we developed an analysis of fire ignition patterns using human and biophysical explanatory variables by firstly developing two different linear models to assess patterns of fire ignition points in terms of occurrence (presence/absence) and frequency (number of ignition points per area and secondly applying statistical tests to both models to evaluate the most important human and/or biophysical drivers influencing these patterns. The probability of ignition point occurrence and frequency were mapped using the predicted values of the two models in the Apulia region (southern Italy). Our findings revealed that dependent variables (fire ignition occurrence points and frequency) are negatively correlated with population density, but positively correlated for presence of urban areas with a significantly higher likelihood of ignition in cultivated (crop)land, forest, shrubland, grassland, and other natural spaces. The probability of ignition increased with elevation and slope. The maps show that the probability of ignition occurrence is relevant along the coast in the northern and southern parts of the region, especially in urban interfaces with a strong presence of shrubland and Mediterranean maquis. Ignition point frequency was predicted along the coast, particularly in the south and in some densely urbanized inland areas. By adopting the models, forest managers and decision makers may avail of the knowledge gained to design and promote sustainable fire management strategies in the Apulia region. [ABSTRACT FROM AUTHOR]

Influence of forest fires on insect diversity: a case study in Apulia. In this paper we analyze the relationship between forest fires and insect diversity in the Mediterranean environment. Using "distance from the ignition point" as explanatory variable, we developed a number of regression models predicting insect abundance and family richness, as well as some of the most common measures of biodiversity (e.g., Shannon index, Simpson index, Margalef index). We report a case study in a forest area (Bosco "Il Quarto" - 600 ha) located in the National Park of Alta Murgia, Apulia Region (southern Italy). Results show a significant influence of forest fire on insect abundance and family richness and a positive linear relationship between biodiversity and distance from the point of ignition for Coleoptera. Simpson's index, in particular, appears the most suitable indicator for measuring the effects of fires on insect biodiversity in the short term. [ABSTRACT FROM AUTHOR]

Abstract: Submarine caves at the Cape of Otranto in South-Eastern Italy host eccentric stalactites which have been recently recognised as completely biogenic. The possibility to use the calcareous tubules of Polichaete forming the inner texture of the stalactites as suitable samples for radiocarbon dating is described. AMS radiocarbon dating analyses performed on samples taken at different positions along the longitudinal axis of three different stalactites allowed to obtain information about the duration of the formation phase, to determine the growth-rate at different stages of evolution and to establish the complete submarine origin of the stalactites. The comparison of the radiocarbon data obtained for the different studied structures reveal also similarities as well as important differences between single stalactites, supplying new information about their response to environmental changes in the same, confined ecosystem. [Copyright &y& Elsevier]

Abstract: Accelerator mass spectrometry radiocarbon measurements have been carried out on vegetables (C3 and C4 grass) collected in the area surrounding the coal-fired power plant in Cerano (Brindisi, southern Italy) and in the industrial district of Taranto (southern Italy). A depletion of the radiocarbon concentration, with respect to “clean air” reference sites, due to the combustion of fossil fuels and the following release of “14C-free” carbon dioxide into the atmosphere has been measured for both sites. In particular for the site of Cerano the measured values have been related to atmospheric circulation data such as the direction of the prevalent winds. [Copyright &y& Elsevier]

Abstract: Submarine caves at the Cape of Otranto, Italy, contain eccentric stalactites that were recently identified as entirely biogenic. One of these stalactites was sectioned along its longitudinal axis in order to select samples for radiocarbon dating. 14C AMS measurements provided fundamental information for the interpretation of the biogenic process and revealed that the formation of the stalactite continued for approximately 5000years with a decrease in the longitudinal growth rate over time. Measurements of modern organisms were performed to assess the accuracy of the radiocarbon determinations, calibrated in calendar years by measuring the local marine reservoir age. [Copyright &y& Elsevier]

We present the results of AMS radiocarbon dating of human bones recovered in “Grotta Cappuccini”, a prehistoric cave in Galatone, Lecce (Southern Italy). The AMS analysis has confirmed the archaeological dating of the cave to the period between the end of the Copper Age and the early Bronze Age, and has given a fundamental contribution to the chronological definition of an important cultural aspect of the prehistory of Southern Italy. [Copyright &y& Elsevier]

A new facility for 14C-AMS dating and for studies on cultural heritage by ion beam analysis has been put in operation at the University of Lecce, Lecce, Italy. The system is based on a 3 MV TandetronTM accelerator, manufactured by High Voltage Engineering Europa (HVEE). In the 14C-AMS system the three carbon isotopes are injected sequentially in the accelerator with cycle frequencies of up to 1 kHz. Performance tests have shown that the beams can be transported without any loss through the system. The 13C/12C precision of the system is 0.04% and no significant drift in the measured ratios is present. [Copyright &y& Elsevier]

Abstract: The identification of ancient climate fluctuations represents an hard challenge for studies intended to outline the human–environment interaction in fragile ecosystems. The aim of this work is to test the potentialities of carbon stable isotopic content of AMS-dated archaeological plant remains as tool to infer variations in rainfall/temperature regimes. The results obtained in the analysis of the carbon stable isotopic content of 10 plant remains selected among the archaeobotanical remains collected at the archaeological site in Faragola (Apulia, Italy) and radiocarbon-dated by AMS are presented. The variation of δ13C values was considered on a chronological scale covering a time range comprised between the II century BC and the VII century AD. The obtained patterns were also compared with local and global-scale palaeoclimatic records. [Copyright &y& Elsevier]

Abstract: A nuclear microprobe beam line has been installed at CEDAD (Centre for Dating and Diagnostics), University of Salento, Lecce, Italy. The beam line is connected to the −30° port of the high energy switching magnet of a 3MV HVEE 4130HC Tandetron accelerator. It is based on an Oxford Microbeam magnetic quadrupole triplet and its general features are presented. The results of functional tests are presented showing how a lateral spatial resolution as low as ∼2μm has been achieved in vacuum by analysing standard reference material. The results obtained in the analysis of ancient radiocarbon dated biological tissues are presented for the identification and distribution of toxic elements such as Pb. [Copyright &y& Elsevier]

Objective: Rare and complex epilepsies encompass a diverse range of disorders characterized by seizures. We aimed to establish a consensus on key issues related to these conditions through collaboration among experienced neurologists, neuropediatricians, and patient advocacy representatives., Methods: Employing a modified Delphi method, a scientific board comprising 20 physicians and 4 patient advocacy representatives synthesized existing literature with their expertise to formulate statements on contentious topics. A final 32-member expert panel, representing diverse regions of Italy, validated these statements through a two-round voting process, with consensus defined as an average score ≥7., Results: Sixteen statements reached a consensus, emphasizing the necessity for epidemiological studies to ascertain the true prevalence of rare epilepsies. Etiology emerged as a crucial factor influencing therapeutic strategies and outcome prediction, with particular concern regarding prolonged and tonic-clonic seizures. The importance of early implementation of specific drugs and non-pharmacological interventions in the treatment algorithm for developmental and epileptic encephalopathies (DEEs) was underscored. Multidisciplinary care involving experts with diverse skills was deemed essential, emphasizing non-seizure outcomes in adolescence and adulthood., Significance: This national consensus underscores the imperative for personalized, comprehensive, and multidisciplinary management of rare epilepsies/DEEs. It advocates for increased research, particularly in epidemiology and therapeutic approaches, to inform clinical decision-making and healthcare policies, ultimately enhancing patients' outcomes., Plain Language Summary: The modified Delphi method is broadly used to evaluate debated topics. In this work, we sought the consensus on integrated and social care in epilepsy management. Both representatives of high-level epilepsy centers and patients' caregivers were directly involved., (© 2024 The Author(s). Epilepsia Open published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Objective: This study was undertaken to assess the effectiveness/tolerability of adjunctive cenobamate, variations in the load of concomitant antiseizure medications (ASMs) and predictors of clinical response in people with focal epilepsy., Methods: This was a retrospective study at 21 centers participating in the Italian Expanded Access Program. Effectiveness outcomes included retention and responder rates (≥50% and 100% reduction in baseline seizure frequency). Tolerability/safety outcomes included the rate of treatment discontinuation due to adverse events (AEs) and their incidence. Total drug load was quantified as the number of concomitant ASMs and total defined daily dose (DDD). Concomitant ASMs were also classified according to their mechanism of action and pharmacokinetic interactions to perform explorative subgroup analyses., Results: A total of 236 subjects with a median age of 38 (Q 1 -Q 3 = 27-49) years were included. At 12 months, cenobamate retention rate was 78.8% and responders were 57.5%. The seizure freedom rates during the preceding 3 months were 9.8%, 12.2%, 16.3%, and 14.0% at 3, 6, 9, and 12 months. A higher percentage of responders was observed among subjects treated with clobazam, although the difference was not statistically significant. A total of 223 AEs were recorded in 133 of 236 participants, leading to cenobamate discontinuation in 8.5% cases. At 12 months, a reduction of one or two concomitant ASMs occurred in 42.6% and 4.3% of the subjects. The median total DDD of all concomitant ASMs decreased from 3.34 (Q 1 -Q 3  = 2.50-4.47) at baseline to 2.50 (Q 1 -Q 3  = 1.67-3.50) at 12 months (p < .001, median percentage reduction = 22.2%). The highest rates of cotreatment withdrawal and reductions in the DDD were observed for sodium channel blockers and γ-aminobutyric acidergic modulators (above all for those linked to pharmacokinetic interactions), and perampanel., Significance: Adjunctive cenobamate was associated with a reduction in seizure frequency and in the burden of concomitant ASMs in adults with difficult-to-treat focal epilepsy. The type of ASM associated did not influence effectiveness except for a favorable trend with clobazam., (© 2024 The Author(s). Epilepsia published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

CDKL5 deficiency disorder (CDD) is a complex clinical condition resulting from non-functional or absent CDKL5 protein, a serine-threonine kinase pivotal for neural maturation and synaptogenesis. The disorder manifests primarily as developmental epileptic encephalopathy, with associated neurological phenotypes, such as hypotonia, movement disorders, visual impairment, and gastrointestinal issues. Its prevalence is estimated at 1 in 40,000-60,000 live births, and it is more prevalent in females due to the lethality of germline mutations in males during fetal development. This Italian multi-center observational study focused on 34 patients with CDKL5-related epileptic encephalopathy, aiming to enhance the understanding of the clinical and molecular aspects of CDD. The study, conducted across 14 pediatric neurology tertiary care centers in Italy, covered various aspects, including phenotypic presentations, seizure types, EEG patterns, treatments, neuroimaging findings, severity of psychomotor delay, and variant-phenotype correlations. The results highlighted the heterogeneity of seizure patterns, with hypermotor-tonic-spasms sequence seizures (HTSS) noted in 17.6% of patients. The study revealed a lack of clear genotype-phenotype correlation within the cohort. The presence of HTSS or HTSS-like at onset resulted a negative prognostic factor for the presence of daily seizures at long-term follow-up in CDD patients. Despite extensive polypharmacotherapy, including medications such as valproic acid, clobazam, cannabidiol, and others, sustained seizure freedom proved elusive, affirming the inherent drug-resistant nature of CDD. The findings underscored the need for further research to explore response rates to different treatments and the potential role of non-pharmacological interventions in managing this challenging disorder., (© 2024. The Author(s).)

Background: Evidence available on the associations between urban greenness and mental health is mainly based on cross-sectional studies and has relied on 2D indicators of greenness. This longitudinal study aimed at investigating the association between 2D and 3D indicators of green and grey spaces and incident mental health-related outcomes in a large population-based cohort., Methods: Our study used data from 593,894 Italian adults (≥30 years) from the Rome Longitudinal Study. Mental health outcomes were defined using either drug prescriptions (antidepressants, antipsychotics, lithium and other mood stabilisers, and anxiolytics, hypnotics and sedatives), or hospitalisation records (for schizophrenia spectrum disorder, depression, anxiety, stress-related and somatoform, or substance use disorders). We obtained 2D and 3D indicators of green and grey exposures including Normalized Difference Vegetation Index (NDVI), green volume, grey volume, number of trees, and Normalized Difference Green-Grey Volume Index around participants' homes. Cox proportional hazards regression models were developed to estimate the association of green and grey space exposure and psychiatric conditions and medicine use, adjusted for relevant covariates., Results: We found beneficial associations of NDVI and the number of trees with antipsychotic and lithium and other mood stabiliser drugs. We also observed detrimental associations between grey volume and lithium and other mood stabilisers and anxiolytic, hypnotic and sedative drugs. Finally, we found a protective association of the NDGG with lithium and other mood stabilisers (HR: 0.977; 95% CI: 0.965-0.990) and anxiolytic, hypnotic and sedative drugs (HR: 0.851; 95% CI: 0.762-0.950). The associations for hospitalisation for psychiatric conditions were less consistent and generally not statistically significant., Conclusions: Findings suggested that higher greenness areas around residential addresses are associated with reduced use of drugs for psychiatric conditions, while the opposite is true for higher grey space exposure. The study highlights the importance of accurately characterising green and grey spaces, using novel exposure indicators., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Wildfire regimes affected by global change have been the cause of major concern in recent years. Both direct prevention (e.g., fuel management planning) and land governance strategies (e.g., agroforestry development) can have an indirect regulatory effect on wildfires. Herein, we tested the hypothesis that active land planning and management in Italy have mitigated wildfire impacts in terms of loss of ecosystem services and forest cover, and burned wildland-urban interface, from 2007 to 2017. At the national scale, we assessed the effect size of major potential fire drivers such as climate, weather, flammability, socio-economic descriptors, land use changes, and proxies for land governance (e.g., European funds for rural development, investments in sustainable forest management, agro-pastoral activities), including potential interactions, on fire-related impacts via Random Forest modelling and Generalized Additive Mixed Model. Agro-forest districts (i.e., aggregations of neighbouring municipalities with homogeneous forest and agricultural characteristics) were used as spatial units of analysis. Our results confirm that territories with more active land governance show lower wildfire impacts, even under severe flammability and climatic conditions. This study supports current regional, national, and European strategies towards "fire resistant and resilient landscapes" by fostering agro-forestry, rural development, and nature conservation integrated policies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Prader-Willi syndrome (PWS) is a rare and complex genetic disease, with numerous implications on metabolic, endocrine, neuropsychomotor systems, and with behavioural and intellectual disorders. Rare disease patient registries are important scientific tools (1) to collect clinical and epidemiologic data, (2) to assess the clinical management including the diagnostic delay, (3) to improve patients' care and (4) to foster research to identify new therapeutic solutions. The European Union has recommended the implementation and use of registries and databases. The main aims of this paper are to describe the process of setting up the Italian PWS register, and to illustrate our preliminary results., Materials and Methods: The Italian PWS registry was established in 2019 with the aims (1) to describe the natural history of the disease, (2) to determine clinical effectiveness of health care services, (3) to measure and monitor quality of care of patients. Information from six different variables are included and collected into this registry: demographics, diagnosis and genetics, patient status, therapy, quality of life and mortality., Results: A total of 165 patients (50.3% female vs 49.7% male) were included into Italian PWS registry in 2019-2020 period. Average age at genetic diagnosis was 4.6 years; 45.4% of patients was less than 17 years old aged, while the 54.6% was in adult age (> 18 years old). Sixty-one percent of subjects had interstitial deletion of the proximal long arm of paternal chromosome 15, while 36.4% had uniparental maternal disomy for chromosome 15. Three patients presented an imprinting centre defect and one had a de novo translocation involving chromosome 15. A positive methylation test was demonstrated in the remaining 11 individuals but the underlying genetic defect was not identified. Compulsive food-seeking and hyperphagia was present in 63.6% of patients (prevalently in adults); 54.5% of patients developed morbid obesity. Altered glucose metabolism was present in 33.3% of patients. Central hypothyroidism was reported in 20% of patients; 94.7% of children and adolescents and 13.3% of adult patients is undergoing GH treatment., Conclusions: The analyses of these six variables allowed to highlight important clinical aspects and natural history of PWS useful to inform future actions to be taken by national health care services and health professionals., (© 2023. The Author(s).)

Background: Lafora disease (LD) is characterized by progressive myoclonus, refractory epilepsy, and cognitive deterioration. This complex neurodegenerative condition is caused by pathogenic variants in EPM2A/EPM2B genes, encoding two essential glycogen metabolism enzymes known as laforin and malin. Long-term follow-up data are lacking. We describe the clinical features and genetic findings of a cohort of 26 Italian patients with a long clinical follow-up., Methods: Patients with EPM2A/EPM2B pathogenic variants were identified by direct gene sequencing or gene panels with targeted re-sequencing. Disease progression, motor functions, and mental performance were assessed by a simplified disability scale. Spontaneous/action myoclonus severity was scored by the Magaudda Scale., Results: Age range was 12.2-46.2 years (mean:25.53 ± 9.14). Age at disease onset ranged from 10 to 22 years (mean:14.04 ± 2.62). The mean follow-up period was 11.48 ± 7.8 years. Twelve out of the 26 (46%) patients preserved walking ability and 13 (50%) maintained speech. A slower disease progression with preserved ambulation and speech after ≥4 years of follow-up was observed in 1 (11%) out of the 9 (35%) EPM2A patients and in 6 (35%) out of the 17 (65%) EPM2B patients. Follow-up was >10 years in 7 (41.2%) EPM2B individuals, including two harbouring the homozygous p.(D146N) pathogenic variant., Conclusions: This study supports an overall worse disease outcome with severe deterioration of ambulation and speech in patients carrying EPM2A mutations. However, the delayed onset of disabling symptoms observed in the EPM2B subjects harbouring the p.(D146N) pathogenic variant suggests that the underlying causative variant may still influence LD severity., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: The main objective of this study was to estimate the efficacy of influenza vaccination in reducing influenza-attributable hospitalization and emergency room (ER) admission for severe complications and influenza-attributable excess mortality in individuals ≥65 years of age., Methods: We analyzed the ≥65 years-old community (n = 952,822) afferent to the Brescia (Northern Italy) Health Protection Agency, considered an Italian population reference, to evaluate the efficacy of influenza vaccination (seasons 2014-17) in reducing deaths, ER-admissions, and hospitalizations for influenza-related complications in the elderly., Results: A protective effect of influenza vaccination emerged in reducing hospitalization and ER admission for diseases of the respiratory system and for death from all causes in people ≥65 years. The major effect of influenza vaccination was the reduction in risk of death from all causes, increasing with age and comorbidity., Conclusion: Influenza vaccination has reduced the number of ER admissions and hospitalizations caused by influenza-related complications and has prevented death among high-risk groups in elderly ≥65 years, resulting in social and public health cost savings. Stronger or new vaccination strategies are needed to improve vaccination rates among the elderly.

Seasonal influenza continues to be a major cause of illness and death. Vaccination is the most cost-effective prophylaxis to prevent the disease and it is particularly important for people who are at high risk of serious complications derived from influenza, especially for people ≥65 years. In Italy, the influenza vaccination program has been unsuccessful with low rates of uptake in people ≥65 years. We analyzed all the community ≥65 years of the Health Promoting Agency (HPA) of Brescia (northern Italy) to evaluate the propensity attitudes toward influenza vaccination among people ≥65 years in four consecutive seasonal influenza campaigns (from 2014/2015 to 2017/2018). Information about subjects were retrieved from administrative databases. Data from 952,822 records were analyzed. The prevalence of vaccinated subjects in the four campaigns was 38.6%, 33.7%, 37.7%, and 40.1%, respectively. Among vaccinated people, the frequencies of individuals aged 65-69.9 years were lower than the frequencies of those in the other age classes, with highest frequencies of vaccinated people in the 75-79.9 years age-class. Overall, males showed a slightly higher propensity to be vaccinated and the propensity toward vaccination increased with age in both genders. Suffering from a chronic disease increased the propensity to vaccination; hypertension had the highest impact on the propensity whereas suffering from vasculopathy has the opposite effect. The value of this study is the possibility to know the factors that might indicate a propensity to get an influenza vaccination and to consider a different approach to people ≥65 years with the characteristics indicating a lower propensity to vaccination.

Purpose: Early and Intensive Behavioral Treatments are considered to be evidence-based interventions for children with Autism Spectrum Disorder (ASD). Nevertheless, children with ASD might not always have the opportunity to benefit from intensive treatment; new, more accessible and alternative treatment options need to be tested. The aim of this study was to evaluate the effectiveness of the Combined Low-intensive Psychoeducational Intervention (CLI-PEI) delivered to preschoolers with ASD at the end of the pre-primary school day. Methods: A quasi-experimental design study, namely a pretest-posttest alternative-treatment comparison groups design, was used. Treatment sessions were carried out over a period of 12 months. Forty-three individuals with autism were included in the study: 24 received the CLI-PEI and 19 were administered the Treatment As Usual. A pre- and posttreatment assessment was carried out using the Psychoeducational Profile-Third edition and the Vineland Adaptive Behavior Scale. Results: The children who received the CLI-PEI showed better gains in both developmental and maladaptive behaviors; furthermore, increased skills were found in all adaptive domains. Conclusions: The CLI-PEI might seems to be a viable treatment option for children with ASD, when intensive behavioral treatments are not accessible.Implication for rehabilitationChildren with ASD might not always have the opportunity to benefit from intensive treatment.The identification of more accessible, less intensive and less expensive evidence-based psychoeducational interventions might represent an appealing challenge for rehabilitation therapists.Less intensive and less expensive evidence-based interventions might also represent a viable option for children and their families, especially in communities with limited resources for autism.A pragmatic approach including components from evidence-based treatments might guarantee flexibility and the possibility to implement an intervention well-tailored to the specific child needs.CLI-PEI for preschoolers with ASD seems to be a promising pragmatic approach, promoting improvements in developmental, adaptive and maladaptive domains.

Background: The best surgical choice for patients with familial adenomatous polyposis (FAP) is still debated. No prospective trials have been carried out to evaluate the pros and cons of the recommended procedures: total colectomy (ileorectal anastomosis [IRA]) vs restorative proctocolectomy (ileal pouch-anal anastomosis [IPAA]). The aim of this study was to provide a basis for tailored precision surgery in patients with FAP., Methods: We conducted a retrospective review of patients with FAP who underwent surgery and were registered in a dedicated database in Milan, Italy. Twenty-year survival related to surgical approach and prognostic factors were investigated using a Cox regression model., Results: A total of 925 patients underwent surgery between 1947 and 2015: 340 (36.8%) IPAA and 585 (63.2%) IRA. Colorectal cancer (CRC) at surgery was diagnosed in 28.6% of patients and a pathogenic APC variant was identified in 88%. During a median follow-up of 129 months, 150 patients died. The survival probability was significantly higher in the IRA than the IPAA group: 0.82 vs 0.75 (hazard ratio [HR] 0.6, 95% confidence interval [CI] 0.42-0.84). Multivariable regression modeling adjusted for propensity scores showed a similar difference, although no longer significant. Multivariable analysis indicated as independent risk factors CRC (HR 4.68, 95% CI 3.04-7.20) and age at surgery (HR 1.03, 95% CI 1.02-1.06). Among patients without cancer, the main risk factor for shorter survival was older age (HR 1.06, 95% CI 1.04-1.09)., Conclusion: The study confirms excellent long-term results of surgical approaches with IRA and IPAA, suggesting that the best surgical choice may be an individually and clinically tailored approach, preferably at a young age.

Genome-wide association studies (GWASs) have identified loci contributing to total serum bilirubin level. However, no exome-wide approaches have been performed to address this question. Using exome-wide approach, we assessed the influence of protein-coding variants on unconjugated, conjugated, and total serum bilirubin levels in a well-characterized cohort of 773 ambulatory elderly subjects from Italy. Coding variants were replicated in 227 elderly subjects from the same area. We identified 4 missense rare (minor allele frequency, MAF < 0.5%) and low-frequency (MAF, 0.5%-5%) coding variants located in the first exon of the UGT1A1 gene, which encodes for the substrate-binding domain (rs4148323 [MAF = 0.06%; p.Gly71Arg], rs144398951 [MAF = 0.06%; p.Ile215Val], rs35003977 [MAF = 0.78%; p.Val225Gly], and rs57307513 [MAF = 0.06%; p.Ser250Pro]). These variants were in strong linkage disequilibrium with 3 intronic UGT1A1 variants (rs887829, rs4148325, rs6742078), which were significantly associated with total bilirubin level (P = 2.34 × 10(-34), P = 7.02 × 10(-34), and P = 8.27 × 10(-34)), as well as unconjugated, and conjugated bilirubin levels. We also identified UGT1A6 variants in association with total (rs6759892, p.Ser7Ala, P = 1.98 × 10(-26); rs2070959, p.Thr181Ala, P = 2.87 × 10(-27); and rs1105879, p.Arg184Ser, P = 3.27 × 10(-29)), unconjugated, and conjugated bilirubin levels. All UGT1A1 intronic variants (rs887829, rs6742078, and rs4148325) and UGT1A6 coding variants (rs6759892, rs2070959, and rs1105879) were significantly associated with gallstone-related cholecystectomy risk. The UGT1A6 variant rs2070959 (p.Thr181Ala) was associated with the highest risk of gallstone-related cholecystectomy (OR, 4.58; 95% CI, 1.58-13.28; P = 3.21 × 10(-3)). Using an exome-wide approach we identified coding variants on UGT1A1 and UGT1A6 genes in association with serum bilirubin level and hyperbilirubinemia risk in elderly subjects. UGT1A1 intronic single-nucleotide polymorphisms (SNPs) (rs6742078, rs887829, rs4148324) serve as proxy markers for the low-frequency and rare UGT1A1 variants, thereby providing mechanistic explanation to the relationship between UGT1A1 intronic SNPs and the UGT1A1 enzyme activity. UGT1A1 and UGT1A6 variants might be potentially associated with gallstone-related cholecystectomy risk.

PMM2-CDG (PMM2 gene mutations) is the most common congenital disorder of N-glycosylation. We conducted a nationwide survey to characterize the frequency, clinical features, glycosylation and genetic correlates in Italian patients with PMM2-CDG. Clinical information was obtained through a questionnaire filled in by the referral physicians including demographics, neurological and systemic features, neuroimaging data and genotype. Glycosylation analyses of serum transferrin were complemented by MALDI-Mass Spectrometry (MALDI-MS). Between 1996 and 2012, data on 37 Italian patients with PMM2-CDG were collected. All the patients with a severe phenotype were unable to walk unaided, 84 % had severe intellectual disability and 81 % microcephaly. Conversely, among 17 mildly affected patients 82 % had independent ambulation, 64 % had borderline to mild intellectual disability and 35 % microcephaly. Epilepsy and stroke-like events did not occur among patients with the mild phenotype. The rate and extent of systemic involvement were more pronounced in severely affected patients. The L32R misfolding mutation of the PMM2 gene occurred in 70 % of the patients with the mild phenotype and was associated with a less severe underglycosylation of serum Tf at MALDI-MS analyses. Despite their different disease severity, all patients had progressive (olivo)ponto-cerebellar atrophy that was the hallmark clinical feature for the diagnosis. A mild neurological phenotype of PMM2-CDG marked by preserved ambulatory ability and autonomy and associated with L32R mutation is particularly frequent in Italy. PMM2-CDG should be considered in patients with even mild developmental disability and/or unexplained progressive cerebellar atrophy.

Purpose: The 22q13.3 deletion syndrome, also known as Phelan-McDermid syndrome, is a rare genetic disorder characterized by hypotonia, severely impaired development of speech and language, autistic-like behaviour, and minor dysmorphic features. Neurologic problems may include seizures of different types, such as febrile, generalized tonic-clonic, focal, and absence seizures. No peculiar EEG features have been associated with 22q13 deletion syndrome to date. In order to verify if a peculiar clinical and EEG pattern is present in 22q13.3 deletion syndrome, we studied six Italian patients with this chromosome abnormality., Method: Array CGH analysis was carried out in the six subjects (1 male, 5 females, age range 11-30 years, median 19.5). They underwent a complete general and neurologic examinations. The EEG study consisted of at least one awake and one nap-sleep video-EEG recordings and evaluation of other EEGs performed elsewhere., Results: Three subjects suffered from myoclonic or generalized tonic-clonic seizures with a rather benign course; all showed multifocal paroxysmal abnormalities on EEG recording, predominant over the frontal-temporal regions, activated during sleep., Conclusion: 22q13.3 deletion syndrome seems to be associated, at least in a subgroup of patients, with a peculiar clinical and EEG pattern, characterized by a childhood epilepsy with a rather benign evolution and with multifocal paroxysmal EEG abnormalities activated by sleep., (Copyright © 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: In relatively small series, autosomal dominant lateral temporal epilepsy (ADLTE) has been associated with leucine-rich, glioma-inactivated 1 (LGI1) mutations in about 50% of the families, this genetic heterogeneity being probably caused by differences in the clinical characteristics of the families. In this article we report the overall clinical and genetic spectrum of ADLTE in Italy with the aim to provide new insight into its nosology and genetic basis., Methods: In a collaborative study of the Commission of Genetics of the Italian League Against Epilepsy (LICE) encompassing a 10-year period (2000-2010), we collected 33 ADLTE families, selected on the basis of the following criteria: presence of at least two members concordant for unprovoked partial seizures with prominent auditory and or aphasic symptoms, absence of any known structural brain pathology or etiology, and normal neurologic examination. The clinical, neurophysiologic, and neuroradiologic findings of all patients were analyzed and a genealogic tree was built for each pedigree. The probands' DNA was tested for LGI1 mutations by direct sequencing and, if negative, were genotyped with single-nucleotide polymorphism (SNP) array to search for disease-linked copy-number variation CNV. The disease penetrance in mutated and nonmutated families was assessed as a proportion of obligate carriers who were affected., Key Findings: The 33 families included a total of 127 affected individuals (61 male, 66 female, 22 deceased). The age at onset ranged between 2 and 60 years (mean 18.7 years). Ninety-one patients (72%) had clear-cut focal (elementary, complex, or secondarily generalized) seizures, characterized by prominent auditory auras in 68% of the cases. Other symptoms included complex visual hallucinations, vertigo, and déjà vu. Aphasic seizures, associated or not with auditory features, were observed in 20% of the cases, whereas tonic-clonic seizures occurred in 86% of the overall series. Sudden noises could precipitate the seizures in about 20% of cases. Seizures, which usually occurred at a low frequency, were promptly controlled or markedly improved by antiepileptic treatment in the majority of patients. The interictal electroencephalography (EEG) studies showed the epileptiform temporal abnormalities in 62% of cases, with a slight predominance over the left region. Magnetic resonance imaging (MRI) or computerized tomography (CT) scans were negative. LGI1 mutations (missense in nine and a microdeletion in one) were found in only 10 families (30%). The patients belonging to the mutated and not mutated groups did not differ except for penetrance estimate, which was 61.3% and 35% in the two groups, respectively (chi-square, p = 0.017). In addition, the disease risk of members of families with mutations in LGI1 was three times higher than that of members of LGI1-negative families (odds ratio [OR] 2.94, confidence interval [CI] 1.2-7.21)., Significance: A large number of ADLTE families has been collected over a 10-year period in Italy, showing a typical and homogeneous phenotype. LGI1 mutations have been found in only one third of families, clinically indistinguishable from nonmutated pedigrees. The estimate of penetrance and OR, however, demonstrates a significantly lower penetrance rate and relative disease risk in non-LGI1-mutated families compared with LGI1-mutated pedigrees, suggesting that a complex inheritance pattern may underlie a proportion of these families., (Wiley Periodicals, Inc. © 2013 International League Against Epilepsy.)

Objective: To perform an extensive search for genomic rearrangements by microarray-based comparative genomic hybridization in patients with epilepsy., Design: Prospective cohort study., Setting: Epilepsy centers in Italy., Patients: Two hundred seventy-nine patients with unexplained epilepsy, 265 individuals with nonsyndromic mental retardation but no epilepsy, and 246 healthy control subjects were screened by microarray-based comparative genomic hybridization., Main Outcome Measures: Identification of copy number variations (CNVs) and gene enrichment., Results: Rare CNVs occurred in 26 patients (9.3%) and 16 healthy control subjects (6.5%) (P = .26). The CNVs identified in patients were larger (P = .03) and showed higher gene content (P = .02) than those in control subjects. The CNVs larger than 1 megabase (P = .002) and including more than 10 genes (P = .005) occurred more frequently in patients than in control subjects. Nine patients (34.6%) among those harboring rare CNVs showed rearrangements associated with emerging microdeletion or microduplication syndromes. Mental retardation and neuropsychiatric features were associated with rare CNVs (P = .004), whereas epilepsy type was not. The CNV rate in patients with epilepsy and mental retardation or neuropsychiatric features is not different from that observed in patients with mental retardation only. Moreover, significant enrichment of genes involved in ion transport was observed within CNVs identified in patients with epilepsy., Conclusions: Patients with epilepsy show a significantly increased burden of large, rare, gene-rich CNVs, particularly when associated with mental retardation and neuropsychiatric features. The limited overlap between CNVs observed in the epilepsy group and those observed in the group with mental retardation only as well as the involvement of specific (ion channel) genes indicate a specific association between the identified CNVs and epilepsy. Screening for CNVs should be performed for diagnostic purposes preferentially in patients with epilepsy and mental retardation or neuropsychiatric features.

A splice site variation (c.603-91G>A or rs3812718) in the SCN1A gene has been claimed to influence efficacy and dose requirements of carbamazepine and phenytoin. We investigated the relationship between c.603-91G>A polymorphism and response to antiepileptic drugs (AEDs) in 482 patients with drug-resistant and 401 patients with drug-responsive focal epilepsy. Most commonly used AEDs were carbamazepine and oxcarbazepine. The distribution of c.603-91G>A genotypes was similar among drug-resistant and drug-responsive subjects, both in the entire population and in the groups treated with carbamazepine or oxcarbazepine. There was no association between the c.603-91G>A genotype and dosages of carbamazepine or oxcarbazepine. These findings rule out a major role of the SCN1A polymorphism as a determinant of AED response., (Wiley Periodicals, Inc. © 2011 International League Against Epilepsy.)

Autism is a complex neurodevelopmental disorder, likely encompassing multiple pathogenetic components. The aim of this study is to begin identifying at least some of these components and to assess their association with biological endophenotypes. To address this issue, we recruited 245 Italian patients with idiopathic autism spectrum disorders and their first-degree relatives. Using a stepwise approach, patient and family history variables were analyzed using principal component analysis ("exploratory phase"), followed by intra- and inter-component cross-correlation analyses ("follow-up phase"), and by testing for association between each component and biological endophenotypes, namely head circumference, serotonin blood levels, and global urinary peptide excretion rates ("biological correlation phase"). Four independent components were identified, namely "circadian & sensory dysfunction," "immune dysfunction," "neurodevelopmental delay," and "stereotypic behavior," together representing 74.5% of phenotypic variance in our sample. Marker variables in the latter three components are positively associated with macrocephaly, global peptiduria, and serotonin blood levels, respectively. These four components point toward at least four processes associated with autism, namely (I) a disruption of the circadian cycle associated with behavioral and sensory abnormalities, (II) dysreactive immune processes, surprisingly linked both to prenatal obstetric complications and to excessive postnatal body growth rates, (III) a generalized developmental delay, and (IV) an abnormal neural circuitry underlying stereotypies and early social behaviors.

Our study aimed at comparing, over a period of 3 years, the effectiveness of three different educational approaches addressed to children with autism and severe mental retardation. The first one was a treatment and education of autistic and related communication handicapped children (TEACCH) program implemented in a residential center; the second was a TEACCH program implemented at home and at mainstream schools, after a specific parent psychoeducational training; the third approach referred to inclusive education in mainstream schools, in which a nonspecific approach was implemented. Each subject was assessed twice, using the Psycho-Educational Profile-Revised (PEP-R) and Vineland Adaptive Behavior Scale (VABS)-survey form. Effectiveness of TEACCH appeared to be confirmed, showing positive outcomes in the natural setting, and revealing its inclusive value.

Background: There is no agreement on the prevalence, natural history and outcome of infantile spasms (IS) in neurofibromatosis type 1 (NF1). By contrast, its prevalence and outcome are well characterised in the setting of other neurocutaneous disorders (e.g. tuberous sclerosis)., Materials and Methods: The aim of the present study was to try to establish a genotype-phenotype correlation in IS in the setting of NF1. A retrospective (years 1990-2000) and prospective (years 2000-2006) study in three paediatric centres in Italy were taken as referral populations for: (1) children with NF1 and (2) neurological problems in childhood., Results: Ten NF1 patients have had IS. The calculated population-based: (1) prevalence of IS in NF1 (0.76%) was higher than the reported frequency of IS in the general population (0.02-0.05%) and (2) frequency of NF1 in the IS series in two out of three centres (0.62-0.90%) was lower than the estimated frequencies in the literature (1.5-3.0%). Patients had psychomotor delay preceding the spasms (50%), symmetrical spasms (50%), typical (80%) and modified (20%) hypsarrhythmia and foci of spikes and waves and a good response to corticosteroid treatment (50%). Outcome was good in 30%. Imaging revealed high-signal foci in atypical locations (sub-cortical and central brain regions). Deoxyribonucleic acid analysis revealed three novel NF1 gene mutations without genotype-phenotype correlation., Conclusion: Even though the combination of IS and NF1 does not seem to be coincidental, it is certainly an unusual event in NF1--rarer than in other neurocutaneous disorders. Spasms in NF1 are not associated with specific genetic defects.

Background: Optimizing dual-chamber pacing to prevent recurrences of atrial tachyarrhythmias (AT) in sinus node dysfunction is still debated. Despite the large number of studies, efficacy of sophisticated preventive algorithms has never been proven. It is not clear whether this is due to imperfect study designs or to a substantial inefficacy of pacing therapies., Aim: To intraindividually compare AT burden between an atrial overdrive and two heart rate modulation approaches: a conventional accelerometric-sensor-based DDDR mode and a contractility-driven rate responsive closed loop (CLS) algorithm., Methods and Results: Four hundred fifty-one patients with Brady-Tachy syndrome (BTS), severe bradycardia, and a documented episode of atrial fibrillation were enrolled. One month after implant, each pacing therapy was activated for 3 months in random order. A simple log transformation was used to handle large and skew AT burden distributions. Estimates were adjusted for false-positive AT episodes and reported as geometric means (95% confidence interval). A significantly higher AT burden was observed during overdrive, 0.14% (0.09%, 0.23%) (adjusted, 0.12%[0.07%, 0.20%]). Both DDDR and CLS performed better: respectively, 0.11% (0.07%, 0.17%) (adjusted, 0.08%[0.05%, 0.14%]), 0.06% (0.03%, 0.09%) (adjusted, 0.04%[0.03%, 0.07%]). All the comparisons were statistically significant. During overdrive significantly more patients had AT episodes of duration between 1 minute and 1 hour. No significant differences were observed for longer episodes., Conclusions: Atrial overdrive showed the worst performance in terms of AT burden reduction and should not be preferred to heart rate modulation approaches that still have to be considered as a first-choice pacing mode in BTS.

The gastrin-releasing peptide receptor (GRPR) was implicated for the first time in the pathogenesis of Autism spectrum disorders (ASD) by Ishikawa-Brush et al. [Ishikawa-Brush et al. (1997): Hum Mol Genet 6: 1241-1250]. Since this original observation, only one association study [Marui et al. (2004): Brain Dev 26: 5-7] has further investigated, though unsuccessfully, the involvement of the GRPR gene in ASD. With the aim of contributing further information to this topic we have sequenced the entire coding region and the intron/exon junctions of the GRPR gene in 149 Italian autistic patients. The results of this study led to the identification of four novel point mutations, two of which, that is, C6S and L181F, involve amino acid changes identified in two patients with ASD and Rett syndrome, respectively. Both the leucine at position 181 and the cysteine at position 6 are strongly conserved in vertebrates. C6S and L181F mutant proteins were expressed in COS-7 and BALB/3T3 cells, but they did not affect either GRP's binding affinity or its potency for stimulating phospholipase C-mediated production of inositol 1,4,5-trisphosphate. In summary, our results do not provide support for a major role of the GRPR gene in ASD in the population of patients we have studied. However, there is a potential role of C6S and L181F mutations on GRPR function, and possibly in the pathogenesis of the autistic disorders in the two patients., (2008 Wiley-Liss, Inc.)

Objectives: Mutations in the EFHC1 gene have been reported in six juvenile myoclonic epilepsy (JME) families from Mexico and Belize. In this study, we screened 27 unrelated JME Italian families for mutations in the EFHC1 gene., Materials and Methods: Twenty-seven families (86 affected individuals, 52 women) with at least two affected members with JME were selected. DNA was isolated from peripheral blood lymphocytes by standard methods and each exon of the EFHC1 gene was amplified and sequenced using intronic primers., Results: Two heterozygous mutations were identified in three unrelated families. One (R353 W) was a novel missense mutation, while the F229 L mutation was previously described (say which on of the two occurred in two families). Both mutations cosegregated with the disease. In a fourth family, the variant 545G-->A (resulting in the amino acid substitution R182 H) cosegregated with JME., Conclusions: The results of our study extend the distribution of EFHC1 mutations to the white population and confirm the high level of genetic heterogeneity associated with JME.

Organophosphates (OPs) are routinely used as pesticides in agriculture and as insecticides within the household. Our prior work on Reelin and APOE delineated a gene-environment interactive model of autism pathogenesis, whereby genetically vulnerable individuals prenatally exposed to OPs during critical periods in neurodevelopment could undergo altered neuronal migration, resulting in an autistic syndrome. Since household use of OPs is far greater in the USA than in Italy, this model was predicted to hold validity in North America, but not in Europe. Here, we indirectly test this hypothesis by assessing linkage/association between autism and variants of the paraoxonase gene (PON1) encoding paraoxonase, the enzyme responsible for OP detoxification. Three functional single nucleotide polymorphisms, PON1 C-108T, L55M, and Q192R, were assessed in 177 Italian and 107 Caucasian-American complete trios with primary autistic probands. As predicted, Caucasian-American and not Italian families display a significant association between autism and PON1 variants less active in vitro on the OP diazinon (R192), according to case-control contrasts (Q192R: chi2=6.33, 1 df, P<0.025), transmission/disequilibrium tests (Q192R: TDT chi2=5.26, 1 df, P<0.025), family-based association tests (Q192R and L55M: FBAT Z=2.291 and 2.435 respectively, P<0.025), and haplotype-based association tests (L55/R192: HBAT Z=2.430, P<0.025). These results are consistent with our model and provide further support for the hypothesis that concurrent genetic vulnerability and environmental OP exposure may possibly contribute to autism pathogenesis in a sizable subgroup of North American individuals.

Background: The HOXA1 gene plays a major role in brainstem and cranial morphogenesis. The G allele of the HOXA1 A218G polymorphism has been previously found associated with autism., Methods: We performed case-control and family-based association analyses, contrasting 127 autistic patients with 174 ethnically matched controls, and assessing for allelic transmission disequilibrium in 189 complete trios., Results: A, and not G, alleles were associated with autism using both case-control (chi(2) = 8.96 and 5.71, 1 df, p <.005 and <.025 for genotypes and alleles, respectively), and family-based (transmission/disequilibrium test chi(2) = 8.80, 1 df, p <.005) association analyses. The head circumference of 31 patients carrying one or two copies of the G allele displayed significantly larger median values (95.0th vs. 82.5th percentile, p <.05) and dramatically reduced interindividual variability (p <.0001), compared with 166 patients carrying the A/A genotype., Conclusions: The HOXA1 A218G polymorphism explains approximately 5% of the variance in the head circumference of autistic patients and represents to our knowledge the first known gene variant providing sizable contributions to cranial morphology. The disease specificity of this finding is currently being investigated. Nonreplications in genetic linkage/association studies could partly stem from the dyshomogeneous distribution of an endophenotype morphologically defined by cranial circumference.

Objectives: SCN1A mutations were recently reported in several patients with severe myoclonic epilepsy in infancy (SMEI). The authors analyzed SCN1A mutations in 93 patients with SMEI and made genotype-phenotype correlation to clarify the role of this gene in the etiology of SMEI., Methods: All patients fulfilled the criteria for SMEI. The authors analyzed all patients for SCN1A mutations using denaturing high performance liquid chromatography. If a patient's chromatogram was abnormal, the authors sequenced the gene in the patient and both parents., Results: SCN1A mutations were identified in 33 patients (35%). Most mutations were de novo, but were inherited in three patients. Parents carrying the inherited mutations had either no symptoms or a milder form of epilepsy. A greater frequency of unilateral motor seizures was the only clinical difference between patients with SCN1A mutations and those without. Truncating mutations were more frequently associated with such seizures than were missense mutations. The percentage of cases with family history of epilepsy was significantly higher in patients with SCN1A mutations., Conclusions: Unilateral motor seizures may be a specific clinical characteristic of SMEI caused by SCN1A mutations. Ten percent of SCN1A mutations are inherited from an asymptomatic or mildly affected parent, suggesting that SMEI is genetically heterogeneous. The increased frequency of familial epilepsy indicates that other genetic factors may contribute to this disorder.

Purpose: This collaborative study by three Italian groups of child neuropsychiatrists was carried on to evaluate the efficacy and safety of the classic 4:1 ketogenic diet as add-on treatment in refractory partial or generalized epilepsy in children, adolescents and young adults., Methods: We performed a prospective add-on study in 56 refractory epilepsy young patients (age 1-23 years, mean 10.4 years), all with both symptomatic and cryptogenic, generalized or partial epilepsies. Child neuropsychiatrists worked with nutritional team for sample selection and patients management. The ketogenic diet was added to the baseline antiepileptic drugs and the efficacy was rated according to seizure type and frequency. During treatment, seizure frequency, side effects, urine and blood ketone levels and other parameters were systematically evaluated., Results: Patients have been treated for 1-18 months (mean 5 months). A >50% reduction in seizure frequency was gained in 37.5 and 26.8% of patients after 3 and 6 months, respectively, at 12 months, this number fell by 8.9%. No significant relationship between diet efficacy and seizure or epilepsy type, age at diet onset, sex and etiology of epilepsy was noted. Nevertheless, it seems noteworthy that 64% of our patients with neuronal migration disorders improved on this diet. Adverse effects occurred, mainly in the first weeks of treatment, in 32 patients (57.1%), but were generally mild and transient. In seven patients (12.5%) it was possible to withdraw one to two AED after 3-4 months on ketogenic diet., Conclusion: This initial experience with the ketogenic diet was effective in difficult-to-treat patients with partial and generalized epilepsies, though its efficacy dropped significantly by 9-12 months.

Reduced adenosine deaminase (ADA) activity has been reported in sera of autistic children relative to controls. Additionally, the Asn allele of the ADA Asp8Asn polymorphism has been associated with reduced enzymatic activity. Therefore, we studied this polymorphism in autistic children and controls from two Italian populations. We observed a significantly elevated frequency of the low-activity Asn allele in the total sample of autistic cases relative to controls (P < 0.00001), and in both study populations (P < 0.001 and P < 0.025). We suggest that this putative genotype-dependent reduction in ADA activity may be a risk factor for the development of autism.