Determination of Ginsenosides (Ginseng Saponins) in Dry Root Powder from Panax ginseng, Panax quinquefolius, and Selected Commercial Products by Liquid Chromatography: Interlaboratory Study

Twelve collaborating laboratories assayed 4 products, namely, Panax ginseng, Panax quinquefolius, and 2 ginseng products, for 6 ginsenosides: Rb1, Rb2, Rc, Rd, Re, andRg1. Collaborators also received a negative control for the recovery study. Pure ginsenosides were provided as reference standards for the liquid chromatography (LC) analysis and the system suitability tests. The LC analyses were performed on the methanol extract using UV detection at 203 nm. For P. ginseng, individual ginsenosides were consistent in their means; repeatability standard deviations (RSDr)rangedfrom4.17to5.09% and reproducibility standard deviations (RSDR) ranged from 7.27 to 11.3%. For P. quinquefolius, the Rb1 and Rb2 ginsenosides were higher and lower in concentration than P. ginseng, with RSDr values of 3.44 and 6.60% and RSDR values of 5.91 and 12.6% respectively, and other analytes at intermediate precisions. For ginseng commercial products, RSDr values ranged from 3.39 to 8.12%, andRSDR values ranged from 7.65 to 16.5%. A recovery study was also conducted for 3 ginsenosides: Rg1, Re, andRb1. The average recoveries were 99.9, 96.2, and 92.3%, respectively. The method is not applicable for the determination of Rg1 and Re in ginseng product at levels <300 mg/kg.

Magnetoencephalographic yield of interictal spikes in temporal lobe epilepsy. Comparison with scalp EEG recordings

To compare magnetoencephalography (MEG) with scalp electroencephalography (EEG) in the detection of interictal spikes in temporal lobe epilepsy (TLE), we simultaneously recorded MEG and scalp EEG with a whole-scalp neuromagnetometer in 46 TLE patients. We visually searched interictal spikes on MEG and EEG channels and classified them into three types according to their presentation on MEG alone (M-spikes), EEG alone (E-spikes), or concomitantly on both modalities (M/E-spikes). The M-spikes and M/E-spikes were localized with MEG equivalent current dipole modeling. We analyzed the relative contribution of MEG and EEG in the overall yield of spike detection and also compared M-spikes with M/E-spikes in terms of dipole locations and strengths. During the 30- to 40-min MEG recordings, interictal spikes were obtained in 36 (78.3%) of the 46 patients. Among the 36 patients, most spikes were M/E-spikes (68.3%), some were M-spikes (22.1%), and some were E-spikes (9.7%). In comparison with EEG, MEG gave better spike yield in patients with lateral TLE. Sources of M/E- and M-spikes were situated in the same anatomical regions, whereas the average dipole strength was larger for M/E- than M-spikes. In conclusion, some interictal spikes appeared selectively on either MEG or EEG channels in TLE patients although more spikes were simultaneously identified on both modalities. Thus, simultaneous MEG and EEG recordings help to enhance spike detection. Identification of M-spikes would offer important localization of irritative foci, especially in patients with lateral TLE.

The effect of intra-operative video on patient anxiety

We conducted a randomised controlled study to evaluate whether watching video compact discs intra-operatively using a liquid crystal display (LCD) unit decreased anxiety. Forty-four patients undergoing elective surgery under regional anaesthesia were assigned to either the LCD or control group. Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI) and visual analogue score (VAS). The mean (SD) anxiety trait scores were 46.15 (6.28) and 46.40 (7.32) in the control and LCD groups, respectively. The state anxiety of the LCD group [35.50 (7.96)] measured immediately postoperatively was significantly lower than the control group [41.50 (9.02); p = 0.03]. The median (range) reduction in VAS anxiety score was not significantly greater in the LCD group [20 (20 to 80) mm] compared with the control group [12.5 (70 to 60) mm]. Watching video intra-operatively reduces patient anxiety as measured by the STAI.

Power spectrum analysis of heart rate variability in children with epilepsy

OBJECT

Children with epilepsy have been found to be at increased risk of death during childhood. Sudden unexpected death (SUDEP) has accounted for at least 12% of deaths of children with epilepsy. The exact mechanisms of SUDEP are unknown; however, theories suggested have, to date, focused on autonomic instability. The purpose of this study was to investigate autonomic function in children with chronic epilepsy by means of power spectrum analysis of heart rate variability.

METHODS

Thirty patients with epilepsy and 30 control subjects, all between the ages of 4 and 10 years, were enrolled in this study. Power spectrum analysis of heart rate variability (HRV) was performed under standardized conditions after the patients had rested for 15 min. Each patient was tested in a supine position first and then again in a head-up tilted position, with 15 min between the two tests.

RESULTS

There was no significant difference between the low-frequency component (LF) and the high-frequency component (HF) of heart rate variability, or the LF/HF ratio, between the study and control groups, whether the test subjects were in the supine or the head-up tilt position. In the control group, however, the subjects showed a significantly greater LF component and a smaller HF component of heart rate variability, and a greater LF/HF ratio in the head-up position than in the supine position. This implies a normal sympathovagal balance. This phenomenon was not observed in the study group. This implies that the modulating effects on autonomic function deriving from the hemisphere were probably disturbed, owing to the brain lesions that each of the study group patients had already sustained.

CONCLUSIONS

A disturbed balance of activity between the sympathetic and parasympathetic nervous system might result from the loss of hemispheric influence in patients with epilepsy. Nevertheless, further investigation is clearly necessary to ascertain the possible association of this disturbed balance with SUDEP. Further investigation is also needed to establish the exact location of the region in the brain that gives rise to this modulating influence.

Predictors of maternal depression for families having a child with epilepsy

The purpose of this study was to use a descriptive correlational design to examine the relationship among maternal uncertainty, boundary ambiguity and depression in families having a child with epilepsy. Three hundred and twenty-four mothers from the child epilepsy day-clinics of three teaching hospitals in Taiwan participated in this study. Data collection was performed by well-trained research assistants who helped mothers fill out the well-developed Chinese version of the Parental Perception of Uncertainty Scale, the Boundary Ambiguity scale, and the Beck Depression Inventory. Uncertainty was positively associated with boundary ambiguity and depression. Boundary ambiguity was positively associated with depression. Stepwise regression analysis demonstrated that boundary ambiguity, uncertainty and mother's age are predictors of a mother's depression which account for 21.49% of the total variance of depression. The results provide a scientific knowledge base for nursing interventions that aim to provide clear information about the child's illness and help to establish appropriate patterns of parent-child interaction in terms of maintaining family boundary integrity and mothers' functional adaptability.

Lateralizing value of early head turning and ictal dystonia in temporal lobe seizures: a video-EEG study

To investigate early head turning, we retrospectively studied videotapes of 262 seizures from 82 patients who were seizure free after temporal lobectomy. Early head movements were arbitrarily classified into non-tonic turning, tonic turning, and absence of turning. Among the 222 seizures which showed early head turning, 168 (75.7%) had non-tonic turning and 54 (24.3%) had tonic turning. The direction of the first head turning was ipsilateral to the epileptogenic foci in 132 (78.6%) seizures with non-tonic turning and in 35 (64.8%) seizures showing tonic head turning. The proportion of seizures with turning towards the ipsilateral side in the presence of tonic and non-tonic head turning were significantly different (P= 0.04). Seventy-four seizures (28.2%) evolved to secondary generalization, more frequently found in seizures with early head turning (P= 0.0015) and especially those showing tonic turning (P< 0.0001). The direction of head turning immediately preceding secondary generalization was contralateral to the lesion side in 53 seizures (82.8%). Dystonic upper limb posturing occurred in 86 seizures (32.8%), exclusively contralateral to the seizure focus, whereas 65 (75.6%) were associated with initial head turning ipsilateral to the focus. In summary, temporal lobe seizures with tonic head turning tends to secondarily generalize and the direction of head turning before secondarily generalized was contralateral to the seizure foci. Earlier in the seizures the direction of non-tonic head turning tends to be towards the epileptogenic hemisphere. In addition, dystonic posturing of the extremities is a significant lateralizing sign to the contralateral hemisphere in temporal lobe seizures.

Antiepileptic drug withdrawal in patients with temporal lobe epilepsy undergoing presurgical video-EEG monitoring

PURPOSE

To investigate antiepileptic drug (AED) withdrawal during video-EEG monitoring in adult patients with temporal lobe epilepsy (TLE).

METHODS

Between 1995 and 1997, 102 consecutive patients with refractory TLE were admitted to the epilepsy monitoring unit for presurgical evaluation. Patients were monitored with ongoing AEDs being rapidly decreased and discontinued in 4-6 days. The monitoring was continued until sufficient numbers of seizures were recorded. Serum AED levels were checked at admission and after the first complex partial seizure (CPS).

RESULTS

In all, 89 patients had 429 CPSs (mean, 4.8 per patient), including 156 (36.4%) secondarily generalized. A mean of 153.8 h (16-451 h) was required for completing the monitoring in each patient. Forty-three (48.3%) patients experienced seizure clusters, and eight (9.0%) had generalized seizures that had never occurred or had been absent for years. However, none evolved to status epilepticus. Carbamazepine was the most commonly used AED in 71.9% of patients, followed by valproate and phenytoin. When the first CPS occurred, mean 77.2 h since the beginning of the monitoring, serum levels of these three AEDs were mostly subtherapeutic rather than minimal.

CONCLUSIONS

Acute AED withdrawal effectively provoked seizures in TLE patients undergoing presurgical video-EEG monitoring. However, nearly 50% of patients had seizure clusters or secondarily generalized seizures. Serum AED levels were mostly subtherapeutic when the first CPS occurred.

Seizure outcomes after anterior callosotomy in patients with posterior-dominant and with anterior-dominant epileptiform discharges

OBJECTS

We wished to find whether there was any difference in the postoperative seizure outcome between patients with bisynchronous anterior-dominant and those with posterior-dominant EDs after anterior callosotomy.

METHODS

Seizure outcomes after anterior callosotomy in 7 patients with bisynchronous posterior-dominant epileptiform discharges and in 54 patients with anterior-dominant seizures were compared. All 61 cases had been followed up for more than 2 years after operation. One patient (14.3%) had become seizure free. Two patients (28.6%) had more than 50% reduction in seizure frequency, but 4 patients (57.2%) showed no improvement at all. The percentage of cases with significant improvement (more than 50% reduction of seizure frequency) was 43% (3 in 7), which is lower than in the patients with bisynchronous anterior-dominant EDs (64.8%).

CONCLUSIONS

Our preliminary results suggest that anterior partial callosotomy could still be helpful in cases with bisynchronous posterior-dominant epileptiform discharges but the prognosis may be less optimistic than for those with anteriorly located discharges.

Identification and characterization of Podophyllum emodi by API-LC/MS/MS

An API-LC/MS/MS method was developed for the identification of the medicinal herb Podophyllum emodi based on the profile of its aryltetrahydronapthalene and related lignan marker compounds. This was done by matching the structural information from the tandem mass spectrometric data with those lignan marker compounds already reported for the herb. The method could be employed in the absence of reference standards for the markers and was particularly useful in view of the scarcity of supply of these chemical standards. It has been used successfully to differentiate Podophyllum emodi from two commonly used medicinal herbs of a different genus but having similar appearance, Radix clematidis and Radix gentiana, as well as a closely related herb, Podophyllum peltatum.

Transcultural oral health care: 2. Developing transcultural oral health promotional materials

This paper discusses the common problems involved in developing transcultural oral health promotional materials, and describes the best ways to avoid them. Translation errors and poor illustrations are by far the most frequently encountered problems followed by cultural incompatibility, inadequate information, and text and layout mistakes.

Transcultural oral health care and the Chinese--an invisible community

The Chinese, a 'silent minority', are the most scattered, but neglected, community in the UK. Most dentists will have at least a few Chinese people in their community. This paper describes the health beliefs, dental knowledge, attitudes and behaviours of the Chinese. Implications for general dental practitioners are discussed.

Postcallosotomy seizure outcome in hemiconvulsion-hemiatrophy-epilepsy syndrome

Recently, three patients with hemiconvulsion-hemiplegia-epilepsy syndrome who underwent callosotomy were monitored for more than four years. All patients had atrophy of the right brain hemisphere with left hemiparesis and seizures. Two cases were probably the result of traumatic intracranial hemorrhage and one was due to an unknown cause. Wada tests were done in cases 1 and 2, which showed spared motor function of the atrophic hemisphere, supporting the choice of callosotomy instead of hemispherectomy. Patient 1 had atypical absence seizures and asymmetric generalized tonic seizures before surgery, the latter of which decreased by about 60% after callosotomy. Patient 2 had simple partial seizures of the motor type and complex partial seizures, the latter of which were also induced by touch (somatosensory-induced reflex epilepsy). This patient's complex partial seizures disappeared completely, but the simple partial seizures remained unchanged. Patient 3 had generalized tonic seizures, simple partial seizures of the sensory type and complex partial seizures. After surgery, the frequency of the generalized tonic seizures decreased more than 90%. The simple partial seizures of the sensory type remained unchanged. There were two new types of seizures after surgery, simple partial seizures of the motor type and brief generalized myoclonic jerks. All patients had significant reductions in numbers of seizures of more than 50%.

Postictal psychosis with forced normalization

A 22-year-old female patient with epilepsy for more than six years who had prominent psychiatric manifestations, including paranoia, delusions and hallucinations, after a series of major seizure attacks caused by sudden withdrawal of anticonvulsant medication was monitored. This reported episode of psychosis occurred eight hours after the last seizure attack and lasted for two weeks. The psychosis gradually disappeared after administration of lorazepam. The electroencephalogram (EEG) performed during the period of psychosis showed intermittent slow activity in the bilateral frontal regions of the brain. There were active bisynchronous epileptiform discharges bisynchronously in both frontotemporal regions after the resolution of the psychotic episode. The clinical picture and course were consistent with the diagnosis of "postictal psychosis", and the transient near normal EEG during psychosis was most likely a phenomenon known as "forced normalization". The patient has not had a similar psychotic attack since the one reported here.

Mah-jong epilepsy: a new reflex epilepsy

BACKGROUND

Flickering light and color patterns, reading, language, movement, decision making, eating, tapping and touching, hot water immersion and auditory stimulation can induce seizures in some patients. This is known as "reflex epilepsy". The mechanism of reflex epilepsy is not clear. Recently, we cared for 12 patients (11 men and 1 woman, age 41-74 years; mean age = 63.1 years) whose seizures were induced by playing mah-jong, with mean age at seizure onset of 48.7 years. Nine of the 12 patients had seizures exclusively while playing mah-jong.

METHODS

We retrospectively reviewed the medical records of 12 epileptic patients who visited our neurologic clinic from 1987 to 1999, with the chief complaint of mah-jong induced seizures. All patients underwent examinations including electroencephalography, brain computed tomography or magnetic resonance imaging, analysis of clinical manifestation of seizures, family history and past medical history. All were given anticonvulsant therapy for preventing seizures.

RESULTS

Clinically, 10 patients had generalized tonic-clonic seizures and two patients had partial seizures with secondary generalization. Interictally, normal results on EEG were found in six patients, three had focal temporal spikes, and three had intermittent slow activity in the frontotemporal regions. Neuroimaging studies of the brain were normal in seven patients, two had lacunar infarctions, one had generalized atrophy and one had focal left parietal lesions of an unclear nature. Only one patient had a family history of epilepsy. All 12 patients received anticonvulsant therapy, and of these, nine had good epilepsy control.

CONCLUSIONS

"Mah-jong epilepsy," a new reflex epilepsy, is probably related to thinking and decision making while playing mah-jong. The easy control of seizures induced by mah-jong suggests a benign nature. In addition to anticonvulsant therapy, avoiding playing mah-jong may be essential in preventing seizures.

Parental smoking practices and caries experience in pre-school children

Voluntary and involuntary smoking influence general health. Links between voluntary smoking and oral health are confirmed for periodontal diseases and oral cancer/precancer. Since recent reports have suggested an association between parental smoking and caries experience in young children, this study aimed to explore varying patterns of parental smoking, adjusted for social class, with caries prevalence, using data derived from the UK National Diet and Nutrition Survey (1995). Data analysis was confined to 749 children aged 3.0-4.5 years, to avoid confounding effects of unerupted teeth. Bivariate analysis indicated that the prevalence of maternal rather than paternal smoking was significantly related to caries and substantially attenuated social class differences. The reported number of cigarettes smoked was not important. To compensate for the association between social class and maternal smoking, data were dichotomised by social class (manual/non-manual). With caries prevalence as the dependent variable, logistic regression analysis recorded maternal smoking as a significant independent variable in each case, with odds ratios of 1.55/1.96, respectively. The process was repeated for the combined dataset, using the more extensive (six) social class categories. This further analysis yielded an odds ratio for maternal smoking of 1.54 compared with 1.46 for social class. Nutrition status (as growth parameters) and dietary intake (as household spending on confectionery) were not significant independent variables in these equations. The rationale for these findings is discussed. Further research is required to determine mechanisms underlying these observations. It is concluded that maternal smoking is a significant factor to be considered as an additional risk indicator beyond social class when predicting caries risk in young children.

Postoperative seizure outcome after corpus callosotomy in reflex epilepsy

Flickering light and color patterns, reading, language, movement, decision making, eating, tapping and touching, hot water immersion and auditory stimulation can induce seizures in some epileptic patients. These are known as the "reflex epilepsies". The mechanism of reflex epilepsy is not clear. Recently, we performed anterior two-thirds corpus callosotomies in two reflex epilepsy patients (ages 12 and 14 years), with follow-up for more than three years. Patient 1 had Lennox-Gastaut syndrome with auditory-induced generalized atonic or tonic seizures (startle epilepsy), which decreased by 60% after callosotomy. Patient 2 had Lennox-Gastaut syndrome with somatosensory-induced generalized tonic seizures (tap epilepsy). He was seizure-free for one year immediately after callosotomy, but his seizures recurred with the same degree and frequency as before surgery. The nonsignificant postoperative seizure outcome suggests that the corpus callosum only plays a partial role in seizure generation. Our report also discusses the possible mechanisms of generation of reflex seizures.

Coexistence of epilepsy, myasthenia gravis and psoriasis vulgaris

We report the case of a 36-year-old Chinese man with a history of complex partial seizure of temporal lobe origin since the age of 12 years, superimposed by myasthenia gravis since the age of 27 years and psoriasis vulgaris since the age of 29 years. With an eight-year follow-up, the above three diseases remained without complete remission. Anticonvulsant therapy (phenytoin and trimethadione) caused drug-induced myasthenia gravis, which should gradually disappear after discontinuing the drugs. However, the myasthenic symptoms and serum acetylcholine receptor antibody persisted following the discontinuation of phenytoin in our patient. Myasthenia gravis and psoriasis are both autoimmune diseases and correlate with specific human histocompatibility antigens. This suggests a close connection between these two diseases. The coexistence of epilepsy, myasthenia gravis and psoriasis vulgaris has not been previously reported, and to the best of our knowledge, our patient is the first reported case. The relationship among these three diseases requires further investigation.

Seizure outcome after corpus callosotomy: the Taiwan experience

From September 1989 to August 1996, we performed anterior corpus callosotomy in 83 patients. Unfortunately, 9 patients were lost to follow-up. Among the remaining 74 patients, 59 had Lennox-Gastaut syndrome (evolved from infantile spasms in 22), 9 had complex partial seizures with or without secondary generalized seizures, 1 had multifocal independent epileptogenic foci (MISF) syndrome, 3 had hemiconvulsion-hemiplegia-epilepsy (HHE), and 2 had infantile spasms. All cases were followed up for at least 2 years after surgery. The highest rate of significant improvement (more than 50% reduction in seizure frequency) was noted in the patients with generalized tonic-clonic seizures, 82.1% of whom experienced significant improvement, followed by those with generalized tonic seizures (76. 7%), atonic seizures (72.7%), myoclonic seizures (64.9%), atypical absences (58.6%), and complex partial seizure with or without secondary generalization (61.5%). Complete freedom from seizures was noted in 14 cases (18.9%). One patient had the anterior half of his right palm amputated following radial artery thrombosis complicated by insertion of an arterial line during anesthesia. Otherwise, there were no major postoperative complications except for brief mutism and multifocal jerks in some patients during the 1st postoperative week. Thus, we conclude that corpus callosotomy is a safe alternative treatment for all kinds of medically intractable seizures, especially generalized epilepsy.

Diagnostic delays in head and neck cancers

Head and neck cancers are a significant and worsening health problem in the UK. In the absence of screening, minimising diagnostic delay after the onset of symptoms improves prognosis. Delay, from the patient's initial experience of symptoms to the ultimate diagnosis, consists of two elements--the delay prior to presenting to a clinician plus that due to the health professional consulted. This study aimed to establish the period of delay between recognition of the initial tumour symptoms and the formal diagnosis among a sample of patients recently diagnosed with head and neck cancer. Using a semistructured questionnaire, 133 men and 55 women were interviewed by a research nurse, and the results were related to the clinical findings. Tumour size at diagnosis was classified according to T1 (22%), T2 (29%), T3 (27%) and T4 (22%). Of the 186 patients with complete hospital records, 48 (26%) were diagnosed with cancer of the lip and oral cavity (CLOC). From the onset of symptoms to the patients' initial decision to seek professional advice, the median period was 4 weeks among those with CLOC and 3 weeks for those with other head and neck cancers (OHNC). The distribution was highly skewed with delays beyond 6 months occurring among 9% of the OHNC group, compared with 3% of CLOC. From the onset of symptoms to a consultant appointment, the median delay was 8 weeks for OHNC, but 12 weeks for CLOC, with delays beyond 6 months of 13% in each group, respectively. First symptoms included 'change in voice' (26%), 'pain' (27%), 'lump' or 'growth' (12%) as well as dysphagia, 'infection', 'sore throat', 'ulcers' or 'abscess'. No significant association was found between the nature of the first symptoms and the urgency with which patients interpreted their symptoms, nor was this related to diagnostic delay, sex, age or social class. It is concluded that there is substantial variation in time to clinical presentation, particularly for OHNC, although professional delay for the majority of these cases was minimal. For patients with CLOC there was less variation in patient delay, but clinician delay was relatively longer.

An exploration of oral health beliefs and attitudes of Chinese in West Yorkshire: a qualitative investigation

This qualitative study explores oral health beliefs and attitudes among Chinese resident in West Yorkshire using six focus groups differentiated by age and gender. Focus group discussions took place in community settings led by trained Chinese facilitators. All groups believed that they were susceptible to dental disease, and that bleeding gums and total tooth loss were 'normal'; apart from the elderly, tooth loss was seen as undesirable. The elderly and adult groups believed in traditional remedies and claimed that preventive oral health measures were ineffective. These groups lacked faith in dentists, and for them cost, language difficulties and lack of awareness were the main reported barriers to accessing dental services. Traditional Chinese oral health beliefs remain influential for the elderly and adult UK Chinese. In contrast, teenagers thought that toothbrushing and sugar restriction would help to prevent dental diseases. The appropriateness of the focus group and interview methods for exploring oral health beliefs for the Chinese are discussed, as are implications of the reported intergenerational differences for oral health promotion strategy in the UK.

Dental beliefs, knowledge and behaviour of Chinese people in the United Kingdom

OBJECTIVE

This study explored oral health beliefs, knowledge and behaviour among a sample of United Kingdom Chinese.

DESIGN

A quota sample of Chinese people, stratified by age and gender, were interviewed by trained and standardised Chinese interviewers using a piloted, validated semi-structured questionnaire.

SUBJECTS

One hundred and fifty-six Chinese people--with similar number of teenagers, younger adults and older people--resident in the North East of England.

SETTING

Chinese communities.

OUTCOME MEASURE

Reported dental knowledge, beliefs and behaviours.

RESULTS

Regardless of gender and age, the majority of respondents believed that it was natural for people to lose all their teeth in old age. Less than half were convinced that they would be able to keep their own teeth for life. The majority of the sample considered that they were susceptible to dental diseases, the consequences of which were thought to be serious. Approximately half presumed that dental diseases were preventable, although the aetiology of dental caries, periodontal disease and tooth loss was poorly understood. While 94% claimed to brush their teeth as part of routine dental care, dental visiting and dietary restriction of sugar intake were reported only in 61% and 30% of the sample respectively. Inter-generational differences were marked; older people tended to have a fatalistic attitude and were least likely to attend the dentist.

CONCLUSIONS

A low level of dental awareness was found among the UK Chinese. In order to facilitate effective health promotion and treatment services, the extent of Chinese people's traditional oral health beliefs and behaviour must be taken into account.

Attitudes of Chinese people toward obtaining dental care in the UK

OBJECTIVE

To explore the attitudes of Chinese people regarding dentists and toward obtaining dental care in the UK.

INTRODUCTION

Injudicious use of general health services has been reported among Chinese people in the UK. In relation to oral healthcare, the extent to which cultural beliefs and values affect use remains uncertain.

SETTING

Chinese communities in the north east of England.

SUBJECTS AND METHODS

A quota sample of 156 Chinese people was recruited in 1996. 50 elderly people, 56 adults, 50 teenagers were interviewed by 5 trained and standardised multilingual Chinese interviewers using a validated structured questionnaire.

RESULTS

Access varied substantially according to age, with the younger generations more likely to obtain dental care without difficulty. Overall, the sample perceived that dentists possessed adequate technical competence, but their patient management skills lacked sensitivity. Older Chinese people placed less trust in dentists. Many elderly people reported problems in finding a UK dentist and would have preferred one of Chinese origin. Potential problems in follow-up prosthetic dental care were also apparent among this age group. Cost, communication problems, anxiety and cultural beliefs were identified as major barriers to dental care.

CONCLUSIONS

There is a clear need to raise cultural awareness among dental professionals as well as to help Chinese people's positive attitudes toward dentists and dental care.

The use of clinical dental auxiliaries as examiners in caries prevalence surveys in the United Kingdom: a feasibility study

OBJECTIVE

This study investigated the use of clinical dental auxiliaries as examiners in caries prevalence surveys of 5- and 12-year-old children in the United Kingdom.

METHODS

A random sample of four therapists and four hygienists was drawn from 23 clinical dental auxiliaries employed in the Community Dental Service in Yorkshire, United Kingdom. Training and calibration were carried out according to national guidelines for caries prevalence surveys. Sixteen 5-year-old and sixteen 12-year-old children were examined in the calibration exercise. Agreement was assessed using 95% confidence intervals of mean dmft/DMFT of the group, sensitivity and specificity values, and kappa statistics on dft/DFT.

RESULTS

For 5-year-old children, a good level of agreement with the standard examiner was achieved with sensitivity scores ranging from 0.84-0.98, specificity scores from 0.93-0.97, and kappa scores from 0.80-0.89. For 12-year-old children, sensitivity scores ranged from 0.56-0.95; specificity scores from 0.93-0.99; and kappa scores from 0.66-0.83. Four examiners failed to achieve the minimum scores on all measurements.

CONCLUSION

It was concluded that clinical dental auxiliaries could be used as examiners in caries prevalence surveys of 5-year-old children. However, in order to attempt to meet the national standard for agreement in surveys of 12-year-old children, four of the eight examiners in the present study would require further training. Possible reasons for this difference are discussed.

The reliability of interview data for age at which infants' toothcleaning begins

A number of studies have reported on the age at which toothbrushing started and drawn important conclusions. Such studies often relied on parental recall of a particular event that occurred some years previously, assuming the quality of retrospectively reported data. The present study aimed to investigate consistency of reporting the age at which toothcleaning began. Mothers from two different cultural backgrounds, 100 Caucasian and 150 Asian living in a deprived inner city area, were interviewed in their homes on two separate occasions, when the sample child was 6-24 months old and again at 3-4 years. Of the 39 Caucasian and 31 Asian mothers who specified an age at which toothbrushing commenced at both interviews, complete agreement occurred among 4 (10%) Caucasian and 2 (6%) Asian mothers, with a variation of +/- 2 months among 12 (31%) and 5 (16%) respectively. Intraclass correlation coefficients were -0.01 for Caucasian and -0.46 for Asian mothers. Kappa values were 0 and -0.09 respectively. Of the 139 mothers who stated that their children's teeth were not cleaned at the time of the first interview, 17 claimed an earlier age than this at the second interview. It was concluded that there was little agreement between the two interviews, although the extent of the variation differed between the two cultural groups. Although these findings represent relatively deprived population groups, caution is recommended in unquestioningly accepting the accuracy of retrospective reporting of oral hygiene practices in dental surveys until evidence of better reliability is available.

Relationship between mesial temporal seizure focus and elevated serum prolactin in temporal lobe epilepsy

We evaluated the relationship between mesial temporal seizure focus and serum prolactin (PRL) in patients before and after they underwent anterior temporal lobectomy (ATL) for medically intractable temporal lobe epilepsy (TLE). These patients had a confirmed unilateral epileptogenic focus in mesial temporal structures, a postictal rise in serum PRL 15 to 20 minutes after onset of complex partial seizures, and were refractory for more than 2 years to antiepileptic drugs. Presurgical interictal serum PRL levels were significantly elevated (16.47 +/- 0.85 ng/mL, n = 62) and declined after ATL to normal values (patients, 9.63 +/- 0.55 ng/mL, n = 54; normal subjects, 8.99 +/- 0.57 ng/mL, n = 52). Serial evaluations indicated that normalization was seen 3 months after surgery (9.42 +/- 1.22 ng/mL, n = 9). The postsurgical reduction in serum PRL was similar in men and women, in patients with epileptogenic focus on either side of mesial temporal structures, and was unaffected by antiepileptic medication. We conclude that PRL is elevated following seizures and that a seizure focus in mesial temporal structures may exert a sustained excitatory influence on PRL release in patients with medically intractable TLE.

Lamotrigine as add-on therapy in adult patients with refractory epilepsy

BACKGROUND

Lamotrigine (LTG), one of the newly developed antiepileptic drugs, is efficacious in treating both partial and generalized seizure disorders including Lennox-Gastaut syndrome. Its effect as an add-on therapy was evaluated in 41 adult Chinese patients with refractory epilepsy. Five of the patients were Lennox-Gastaut syndrome and 36 patients had partial epilepsy.

METHODS

We started LTG at 25 mg or 50 mg per day, respectively, depending on whether the patients were simultaneously taking valproate (VPA) or not. Then, LTG was increased in steps to maximal dosage (200 mg or 400 mg per day) within seven weeks and maintained for three months while pre-existing antiepileptic drugs remained unchanged. The efficacy of LTG therapy was assessed by the reduction in the overall seizure frequency. Hematological and biochemical parameters were checked before and after the trial in all patients.

RESULTS

In all, 38 patients completed the trial. Twenty-two patients (57.9%) had > or = 50% reduction in seizure frequency, including four patients with Lennox-Gastaut syndrome and 18 patients with partial seizures. Among the patients with partial epilepsy, there was no significant difference in the efficacy of LTG whether the seizures were of temporal or extra-temporal origin (p = 0.577). In addition, the efficacy was not determined by the concomitant use of VPA (p = 0.189). Thirteen patients (31.7%) complained of adverse experiences, usually mild and dose-dependent. LTG had to be discontinued in only two patients (4.9%) due to severe side effects. The change in blood cell counts and biochemistry profiles was not significant in any of the patients.

CONCLUSIONS

We conclude that LTG is an efficacious and safe antiepileptic drug for add-on therapy in adult patients with refractory epilepsy.

The diagnostic reliability of clinical dental auxiliaries in caries prevalence surveys--a pilot study

The Nuffield Report recommended the development of further education and training for dental auxiliary personnel. The extent to which clinical dental auxiliaries might carry out oral assessments is under consideration currently. While other countries have employed clinical dental auxiliaries as examiners in national surveys, there is no evidence to suggest that they are able to perform oral assessments effectively in the United Kingdom. This study aimed to investigate the possibility of using dental hygienists or therapists as examiners in epidemiological surveys. Five dentists and three clinical dental auxiliaries were trained and calibrated together using standardised BASCD training procedures. Forty 5-year-old children in Leeds were recruited to the training and calibration exercise. Data were analysed according to BASCD recommendations. There were no differences in performance between dentists and auxiliaries. All examiners fell within 95 percent confidence limits of the group mean dt, mt, ft and dmft. Mean grouped dmft scores for the benchmark examiner, dentists and auxiliaries were 1.92, 1.84 and 1.92 respectively. Sensitivity values for dentists and auxiliaries ranged from 0.54 to 1.00 and 0.80 to 0.94 respectively. Kappa scores were 0.70 to 0.90 for dentists; and 0.82 to 0.87 for the auxiliaries. It was concluded that the dental hygienists and therapist recruited to this study could be used in epidemiological surveys of caries in 5-year-old children.

Case Report: a patient with primary biliary cirrhosis and autoimmune hemolytic anemia

Diseases of an autoimmune nature are well recognized in association with primary biliary cirrhosis. Although autoimmune thyroiditis and many rheumatological conditions are well described in primary biliary cirrhosis, autoimmune haematological diseases have been less well reported. We report on a 66 year old North American Indian man with coincident primary biliary cirrhosis and warm antibody haemolytic anaemia. This case report supports the suggestion of an association between autoimmune haemolytic anaemia and primary biliary cirrhosis.

Quality of life and life satisfaction in families after a child has undergone corpus callostomy

Epilepsy is a chronic neurological condition which can have a detrimen tal effect on patients' quality of life (QOL). We evaluated the overall satisfaction with QOL and changes in QOL in 25 families with children who had undergone corpus callostomy for severe epilepsy. The mean age of seizure onset was 3.4 years, and the mean period from seizure onset to operation was 5.2 years. Mean follow-up was 19.3 months. Twenty of 22 patients had various degrees of mental retardation. Mean reduction in severity of seizure activity was 64%. Nineteen of 25 (76%) parents were satisfied with the surgical result. Eighteen of 25 parents (72%) described a good level of satisfaction with their families QOL after callostomy. Reduction in severity of seizure activity was significantly correlated with how successful families considered the surgery to be and how satisfied they were with their QOL (r = 0.72 and 0.77, respectively). Life domains showing one greatest improvement after callostomy included level of self-care, family life, and school performance. Improvements in level of self-care, family life, and school performance were associated with higher levels of life satisfaction (r = 0.69, 0.60, and 0.59, respectively). Hyperactivity, attention span, and social skills improved significantly in 11 patients after surgery. Callostomy did not improve mental performance. We conclude that improved seizure control after callostomy is also associated with improved QOL.

Ictal speech manifestations in temporal lobe epilepsy: a video-EEG study

To evaluate ictal speech manifestations in complex partial seizures (C PS), we reviewed videotapes of 68 consecutive patients who underwent anterior temporal lobectomy (ATL) for treatment of intractable epilepsy in Taiwan. In all, 261 CPS were collected from their video-EEG (VEEG) recordings. Cerebral speech dominance was determined by intracarotid injection of sodium amobarbital (Wada test) in all cases. Ictal speech manifestations, classified as verbalization or vocalization, occurred in 32 patients (47.1%) with 96 seizures (36.8%). Ictal verbalization occurred in 10 patients (14.7%). Ictal vocalization was observed in 28 patients (41.2%); including 6 patients who also had ictal verbalization. Thirty-six patients (52.9%) had no seizure with ictal speech manifestations. Ictal verbalization had significant lateralization value: 90% of patients with this manifestation had seizure focus in the nondominant temporal lobe (p = 0.049). Seizures of patients with ictal vocalization were not more likely to arise from either temporal lobe. We also observed bilingual patients who exclusively spoke in their mother tongue (Taiwanese) rather than the acquired language (Mandarin) in 72.2% of seizures with verbalization. This finding is significant and contrary to a commonly held notion that the acquired language is used in seizures associated with speech behaviors.

Startle epilepsy presenting as drop attacks: a case report

A case of startle epilepsy, induced by an unexpected touch on the left shoulder of a 3.5 year old boy, was investigated. The startle epilepsy manifested as an atonic drop attack. Neurological examination revealed a mild hemiparesis on the left side. Computed tomography (CT) scanning demonstrated an enhancement over the right parieto-frontal region, suggesting a hemangioma. Interictal electroencephalography (EEG) showed diffuse slowing and asymmetry of background activities with lower amplitude over the right centro-parieto-temporal region. The ictal EEG showed a paroxysmal bilaterally synchronized high amplitude single spike followed by a few slow waves lasting about one second over the bilateral centro-parieto-temporal regions. The seizure resisted anticonvulsant therapy and no significant responses were observed despite the use of combined therapy with valproic acid, phenytoin, primidone and clonazepam.

Congenital muscular dystrophy (non-Fukuyama type): a case report

A Taiwanese girl, aged 12 years, presented with early myogenic hypotonia, multiple joint contractures, mental subnormality and epilepsy. Computerized tomography scanning of the brain showed white matter hyperlucency. According to her clinical manifestations and radiological pictures, the patient could be the fourth oriental case who had the features of occidental-type cerebromuscular dystrophy.

Hypothalamic hamartoma and gelastic epilepsy: a case report

We studied a 6-year-old girl who presented with inappropriate and uncontrollable laughing episodes since age 3. Physical examination revealed a precocious puberty. The luteinizing hormone-releasing hormone (LH-RH) stimulation test showed an increased level of follicle-stimulating hormone (FSH). The interictal electroencephalogram (EEG) was normal. Several laughing fits were documented during video/EEG monitoring. During laughing, the ictal EEG showed a diffuse suppression of background rhythm, prominent over the left mesial temporal region. A mass lesion about 2 x 2 cm in size was found over the suprasellar cistern with a broad base attached to the hypothalamus, which was isodense on a computed tomography (CT) scan, isointense to gray matter on T1-weighted magnetic resonance (MR) imaging and hyperintense on T2-weighted MR imaging. The findings were suggestive of a hypothalamic hamartoma. A variety of anticonvulsants had been used with little or no response to the frequency or duration of the laughing seizures.

Clinical and socioeconomic features of subjects with red cedar asthma. A follow-up study

A follow-up study of 128 subjects with red cedar asthma was conducted to evaluate the clinical and socioeconomic impact of the disease in determining the working status of the subjects after the diagnosis was made. The results suggest that the severity of asthma is not the main determinant of working status. Comparing the data at diagnosis and at follow-up examination, we found that the persistence of exposure resulted in a deterioration in the asthma despite the use of more medications. Subjects who were working were younger and had a larger number of dependents than the subjects who were not working at the time of the follow-up examination. We conclude that the socioeconomic factors are important in determining the working status of subjects with red cedar asthma. To prevent severe impairment and disability, there should be more economic incentives for these subjects to choose other jobs.

Coexistence of Parkinson's disease and myasthenia gravis: a case report

This is a report on a 62-year-old Chinese woman with Parkinson's disease (PD) for 8 years who developed myasthenia gravis (MG) in the last year. In this case, there was no adverse effect of trihexyphenidyl on MG, whereas pyridostigmine worsened the PD.

Generalized neuropathy in Taiwan: an etiologic survey

From July 1988 to June 1989, the etiology was registered of 520 patients with generalized neuropathy in 5 neurological centers in Taiwan. The neuropathy was diabetic in 256 cases (49.23%), alcoholic in 45 (8.65%), inflammatory in 34 (6.53%; including 21 with acute inflammatory demyelinating polyneuropathy, 12 with chronic inflammatory demyelinating polyneuropathy, and 1 with chronic relapsing polyneuropathy), 12 with associated malignancy (2.31%), 9 with dysproteinemia (1.73%), uremic in 22 (4.23%), hereditary motor and sensory in 22 (4.23%), toxic in 14 (2.69%), ischemic in 12 (2.31%), hypothyroidism in 10 (1.92%), nutritional deficiency and malabsorption in 6 (1.15%), chronic liver disease in 4 (0.77%), other diseases in 11 (2.12%) and unclassified in 63 (12.12%). This survey provided a crude etiological picture of generalized neuropathy on this island.

Fibrosing alveolitis: chest radiography and CT as predictors of clinical and functional impairment at follow-up in 26 patients

Findings on the original and follow-up chest radiographs and computed tomographic (CT) scans were correlated with clinical and functional parameters in 26 patients with fibrosing alveolitis. Assessment of chest radiographs included determination of a standard profusion score and an average profusion score. The CT assessment included pattern, extent, and distribution of disease. The standard profusion score showed no significant correlation with clinical or functional parameters (P greater than .05). However, the average profusion score of the six lung zones correlated with severity of dyspnea and with static lung volumes (P less than .01). Extent of irregular linear opacities on CT scans correlated with severity of dyspnea and impairment in gas transfer (carbon monoxide-diffusing capacity) (P less than .01). The profusion of ground-glass opacities on the radiograph showed no significant correlations (P greater than .05). The profusion and extent of ground-glass opacities on CT scans correlated with severity of dyspnea, impairment in gas transfer, and reduction in static lung volumes (P less than .01). Ground-glass opacities on CT scans preceded and predicted the development of irregular linear opacities on follow-up CT scans and correlated with an increase in the average profusion score of the chest radiograph (P less than .01).

Percutaneous transthoracic needle biopsies in the rapid diagnosis of pulmonary tuberculosis

From May, 1987, to December, 1990, 173 percutaneous transthoracic needle biopsies (PTNB) using a 19-gauge spinal needle under uniplane fluoroscopic guidance were performed in 160 patients. Thirty-one patients had a final diagnosis of pulmonary tuberculosis. These patients with tuberculosis underwent a total of 35 biopsies. Twenty of 35 (57%) had definite histologic features of tuberculosis with stainable acid-fast bacilli, 4/35 (11.5%) had granulomatous or caseous lesion consistent with tuberculosis, and 11/35 had nonspecific inflammatory changes. When results were matched with the sputum culture results, 15/35 specimens (43%) provided the exclusive means of diagnosis of tuberculosis. Five of 35 (14%) patients developed postbiopsy pneumothoraces. The overall acceptance by patients was good. This report indicates the potential usefulness of PTNB in the rapid diagnosis of selected cases of suspected pulmonary tuberculosis. The yield was comparable to fiberoptic bronchoscopy, currently commonly used in the diagnosis of pulmonary mycobacterial disease. The procedure was noted for its simplicity.

Diagnosis of tuberculous pleural effusion by the detection of tuberculostearic acid in pleural aspirates

Detection of TBSA was attempted in pleural aspirates of 74 patients with tuberculous and 44 patients with nontuberculous pleural effusion by gas chromatography/mass spectrometry with selected ion monitoring. The results were disappointing with a test sensitivity of 67.6 percent and a specificity of 52.3 percent. In contrast, histologic examination of pleural biopsies gave a diagnostic sensitivity of 71.0 percent. Pleural biopsy remains a better investigational procedure for the diagnosis of tuberculous pleural effusion.

Tongue dyskinesia as an early manifestation of Wilson disease

A 15-year-old boy was diagnosed as having Wilson disease. He perceived involuntary tongue movement and speech disorder since March 1990. The tongue movements presented in the resting state and during action. It contracted transversely and bilaterally with an irregular frequency about 1 Hz. As a result, the sides of the tongue moved to form a narrow central groove. This was quite different from the tongue protrusion of tardive dyskinesia. His speech had imprecise consonants, monopitch, low pitch, low volume, harsh voice, and hyponasality. These suggested that tongue dyskinesia could be an early sign of Wilson disease and was not the main cause of his dysarthria.

Two cases of Nocardia asteroides sternotomy infection treated with ofloxacin and a review of other active antimicrobial agents

Two patients who developed post-operative sternotomy infections due to Nocardia asteroides were treated successfully with ofloxacin, in vitro susceptibility of the organisms being used as a guide to dosage. The place of this drug in the treatment of infection due to Nocardia asteroides merits further investigation.

Ofloxacin penetration into tuberculous pleural effusion

After 3 days of treatment with ofloxacin (300 mg given orally once daily), the drug levels in serum and pleural fluid 2 and 4 h after drug administration in patients with tuberculous pleural effusion were assessed by a rapid high-performance liquid chromatography assay. The levels in serum (mean +/- standard error of the mean [SEM]) were 4.70 +/- 0.14 and 4.63 +/- 0.09 mg/liter 2 and 4 h after administration, respectively, and the levels in pleural fluid (mean +/- SEM) were 3.82 +/- 0.09 and 4.21 +/- 0.08 mg/liter, respectively. The pleural fluid-to-serum ofloxacin ratio at 2 h was 0.82 +/- 0.02 (mean +/- SEM), and the ratio at 4 h was 0.92 +/- 0.02 (mean +/- SEM). This study demonstrated very good penetration of ofloxacin into pleural fluid in tuberculous pleuritis.

Nosocomial tuberculosis in hospital staff. The size of the problem in a Hong Kong chest hospital

In the past three decades, among 831 staff (over 6,862 staff-years) under regular chest radiographic survey in the Grantham Hospital, Hong Kong, the cumulative incidence of active pulmonary tuberculosis requiring treatment was 27 (belonging to 23 staff). Number of cases detected per year ranged from 0 to 3. The mean duration from the beginning of employment to the first evidence of disease was 6.43 years. Although this incidence is low, yet the hospital caters for quite a large number of patients with bacteriologically confirmed tuberculosis, we feel that the active screening program for hospital staff should be maintained, and that review of the situation is also recommended.

Minimal bactericidal and inhibitory concentrations of ofloxacin on Mycobacterium fortuitum at pH 7 and 5: therapeutic implications

Mycobacterium fortuitum infections of sternotomy wounds have been successfully treated with ofloxacin, a fluoroquinolone. We studied the MBCs and MICs in vitro of this antibiotic on the organism under neutral pH (7) and acidic pH (5) and found marked escalation of these values under the latter condition. This provides hints on the therapy of these infections under in vivo settings.

In-vitro activity of ofloxacin against Mycobacterium tuberculosis and its clinical efficacy in multiply resistant pulmonary tuberculosis

The in-vitro susceptibilities to ofloxacin of 159 clinical sputum isolates of Mycobacterium tuberculosis, comprising 95 isolates sensitive to all drugs, 31 isolates resistant to streptomycin or isoniazid or both, 27 isolates resistant to streptomycin, isoniazid and rifampicin and six isolates resistant to rifampicin (and in three cases to other drugs) were determined. Favourable MICs of ofloxacin (0.63-1.25 mg/l) were demonstrated for 147 isolates (92%). Twenty-two patients with resistant strains (including one patient with rifampicin intolerance) were studied: ten were given 300 mg ofloxacin and ten were given 800 mg ofloxacin, once daily in both cases, together with second-line accompanying drugs, for nine months to one year. Two received 800 mg of ofloxacin once daily alone for similar periods. In the 300 mg-ofloxacin group and the 800 mg-ofloxacin group, five and eight patients, respectively, achieved culture conversion; the rest failed. In the former group, the peak serum ofloxacin concentrations were 3.71-8.08 mg/l and the mean sputum/serum ratio was 0.85. In the latter group, the corresponding values were 10-18.7 mg/l, and 0.76, respectively. All patients tolerated the drugs well. Analysing only patients with accompanying drugs, those on ofloxacin 800 mg once daily had more rapid sputum culture conversion than those on ofloxacin 300 mg once daily (Mann-Whitney Wilcoxon Rank Sum Test: P less than 0.05), indicating more rapid bacteriolysis and implying the definite efficacy of ofloxacin when used together with second-line accompanying drugs in the management of resistant tuberculosis.

Ofloxacin and imipenem in the treatment of Mycobacterium fortuitum and Mycobacterium chelonae lung infections

Two patients with Mycobacterium fortuitum and one patient with Mycobacterium chelonae lung infections were treated with ofloxacin and imipenem respectively. Of the former two, one had underlying inactive pulmonary tuberculosis and bronchiectasis and the other had silicosis. The latter had severe underlying bronchiectasis also. The treatments were well tolerated and the patients responded well.