Electroencephalography in encephalopathy and encephalitis

Electroencephalography (EEG) is a useful adjunct to clinical neurological examination, particularly as it may detect subtle or subclinical disturbance of cerebral function and it allows monitoring of cerebral activity over time. Continuous EEG combined with quantitative analysis and machine learning may help identify changes in real time, before the emergence of clinical signs and response to interventions. EEG is rarely pathognomonic in encephalopathy/encephalitis but when interpreted correctly and within the clinical context, certain phenotypes may indicate a specific pathophysiology (eg, lateralised periodic discharges in HSV-1, generalised periodic discharges in sporadic Creutzfeldt-Jakob disease, and extreme delta brushes in anti-n-methyl-D-aspartate receptor autoimmune encephalitis). EEG is included in some specialist guidelines for disease assessment, monitoring and prognostication (ie, hepatic, cancer immunotherapy, viral, prion, autoimmune encephalitis and hypoxic ischaemic encephalopathy). EEG is invaluable for confirming or excluding non-convulsive seizures or status epilepticus, particularly in critically ill patients, and in understanding new concepts such as epileptic encephalopathy and the ictal-interictal continuum.

Genetic control of rhizosheath formation in pearl millet

The rhizosheath, the layer of soil that adheres strongly to roots, influences water and nutrients acquisition. Pearl millet is a cereal crop that plays a major role for food security in arid regions of sub-Saharan Africa and India. We previously showed that root-adhering soil mass is a heritable trait in pearl millet and that it correlates with changes in rhizosphere microbiota structure and functions. Here, we studied the correlation between root-adhering soil mass and root hair development, root architecture, and symbiosis with arbuscular mycorrhizal fungi and we analysed the genetic control of this trait using genome wide association (GWAS) combined with bulk segregant analysis and gene expression studies. Root-adhering soil mass was weakly correlated only to root hairs traits in pearl millet. Twelve QTLs for rhizosheath formation were identified by GWAS. Bulk segregant analysis on a biparental population validated five of these QTLs. Combining genetics with a comparison of global gene expression in the root tip of contrasted inbred lines revealed candidate genes that might control rhizosheath formation in pearl millet. Our study indicates that rhizosheath formation is under complex genetic control in pearl millet and suggests that it is mainly regulated by root exudation.

Neurophysiology contributes to outcome prediction after cardiac arrest

This "Points of View" paper discusses the role of neurophysiology in predicting outcome in patients who have initially survived a cardiac arrest but remain in coma. The authors, from different clinical backgrounds, discuss their individual approaches to neuroprognostication.

Proposal for best practice in the use of video-EEG when psychogenic non-epileptic seizures are a possible diagnosis

The gold-standard for the diagnosis of psychogenic non-epileptic seizures (PNES) is capturing an attack with typical semiology and lack of epileptic ictal discharges on video-EEG. Despite the importance of this diagnostic test, lack of standardisation has resulted in a wide variety of protocols and reporting practices. The goal of this review is to provide an overview of research findings on the diagnostic video-EEG procedure, in both the adult and paediatric literature. We discuss how uncertainties about the ethical use of suggestion can be resolved, and consider what constitutes best clinical practice. We stress the importance of ictal observation and assessment and consider how diagnostically useful information is best obtained. We also discuss the optimal format of video-EEG reports; and of highlighting features with high sensitivity and specificity to reduce the risk of miscommunication. We suggest that over-interpretation of the interictal EEG, and the failure to recognise differences between typical epileptic and nonepileptic seizure manifestations are the greatest pitfalls in neurophysiological assessment of patients with PNES. Meanwhile, under-recognition of semiological pointers towards frontal lobe seizures and of the absence of epileptiform ictal EEG patterns during some epileptic seizure types (especially some seizures not associated with loss of awareness), may lead to erroneous PNES diagnoses. We propose that a standardised approach to the video-EEG examination and the subsequent written report will facilitate a clear communication of its import, improving diagnostic certainty and thereby promoting appropriate patient management.

Somatosensory evoked potentials aid prediction after hypoxic-ischaemic brain injury

Cardiopulmonary resuscitation, basic life support and early defibrillation are leading to more survivors of out-of-hospital cardiac arrest reaching hospital. Once stabilised on an intensive care unit, it can be difficult to predict the neurological outcome using clinical criteria alone, particularly with modern management using sedation, neuromuscular blockade and hypothermia. If we are to prevent ongoing futile life support, it is important to try to identify the majority of patients who, despite best efforts, will not make a meaningful recovery. Somatosensory evoked potentials are widely available electrophysiological tests that can provide an objective biomarker of a poor neurological outcome and assist in predicting the prognosis.

Lower urinary tract dysfunction in children after intravesical ureteric reimplantation surgery under one year of age

OBJECTIVE

To report the results of a study conducted on voiding function in children who have undergone intravesical trans-trigonal Cohen ureteric reimplantation surgery before the age of one year.

SUBJECTS

Twenty-eight children (18 males, 10 females) had surgery at a mean age of 4.9 months (range 8-352 days).

METHODS

Bladder function was assessed at a mean age of 7.3 years using questionnaires, the dysfunctional voiding scoring system, PinQ quality of life tool, uroflowmetry and post-void residuals.

RESULTS

Of the total children, 72% had normal lower urinary tract (LUT) function. Eight children (28%) had evidence of LUT dysfunction, two had urge incontinence, two had giggle incontinence, two had voiding postponement, one had dysfunctional elimination syndrome and one had evidence of dysfunctional voiding. Five of the eight children were managed with continence physiotherapy (urotherapy) and one required ongoing anticholinergic therapy.

CONCLUSION

When compared to the published rates of LUT dysfunction in the general paediatric community, no evidence was found to suggest an increased incidence of bladder dysfunction in children undergoing intravesical Cohen ureteric reimplantation surgery under one year of age.

Hyperventilation during electroencephalography: safety and efficacy

PURPOSE

To determine safety and efficacy of hyperventilation (HV) during electroencephalography (EEG).

METHODS

We report the findings of a prospective multicentre National Service Evaluation of the occurrence of adverse events, seizures and interictal epileptiform discharges seen in association with HV during EEG, in a relatively unselected, largely out patient population of 3475 being investigated predominantly for possible epileptic seizures.

RESULTS

Adverse events occurred rarely, and there were no reported significant cerebrovascular, cardiovascular or respiratory events. Of the 3170 patients suspected of 'epilepsy or possible epilepsy' 69 patients (2.2%) had seizures provoked by HV, but only one (0.03%) had a generalised tonic clonic seizure. The elicitation or increase of interictal epileptiform discharges (IEDs) was seen in 387 (12.2%) of the total 3170 patients with suspected epilepsy who hyperventilated. Furthermore 31 patients (0.9%) had psychogenic non-epileptic seizures.

CONCLUSION

HV is rarely associated with adverse events, but contributes to the diagnosis and classification of seizure disorders in an appreciable proportion of patients with epilepsy and non-epileptic attacks. These findings confirm that HV in selected patients is a valid activation technique in diagnostic EEG, where the potential benefits out weigh the risks, and also provide information that may assist the informed consent process.

Safety and feasibility of autologous bone marrow cellular therapy in relapsing-progressive multiple sclerosis

In this phase I study, we assessed the safety and feasibility of intravenous, autologous bone marrow (BM) cell therapy, without immunosuppressive preconditioning, in six patients with clinically definite, relapsing-progressive multiple sclerosis (MS). Assessment of efficacy was a secondary objective and employed clinical disability rating scales, multimodal evoked potential (MMEP) recordings, and magnetic resonance imaging (MRI) scans. Cells were harvested, filtered and infused intravenously in a day-case procedure that was well tolerated by patients and was not associated with any serious adverse events (AEs). Over a period of 12 months after the therapy, clinical disability scores showed either no change (Extended Disability Status Score, EDSS) or improvement (MS impact scale-29, MSIS-29), and MMEPs showed neurophysiological improvement. MRI scans did not show any significant changes over a post-therapy period of 3 months. The lack of serious adverse effects and the suggestion of a beneficial effect in this small sample of patients with progressive disease justify conducting a larger phase II/III study to make a fuller assessment of the efficacy of mobilization of autologous BM in patients with MS.

Investigation of the cerebral response to flicker stimulation in patients with headache

Migraine affects 10% of the population, yet there is no proven diagnostic test. To date the most promising neurophysiological diagnostic technique has been the analysis of cerebral responses to photic stimulation or flicker (the "H" response). This test has proved to be sensitive in patients with "classic" migraine, but has not been re-evaluated since the introduction of the 1988 International Headache Society (IHS) classification system. In 33 migraineurs, we found that the "H" response was sensitive (86.4%) and specific (97.5%) in those with migraine defined according to IHS Committee as type 1.2.1 (typical aura) and type 1.1 (without aura), but not in basilar migraine (1.2.4).

The rough deal protein is a new kinetochore component required for accurate chromosome segregation in Drosophila

Mutations in the rough deal (rod) gene of Drosophila greatly increase the missegregation of sister chromatids during mitosis, suggesting a role for this gene product in spindle or kinetochore function. The activity provided by rod also appears to be necessary for the recruitment of two known kinetochore components, Zw10 and cytoplasmic dynein. In this paper we describe the cloning of rough deal and an initial cytological characterization of its product. The Rod protein shares no identifiable structural motif with other known proteins, although apparent homologs exist in the genomes of nematode and man. By immunocytochemistry we show that Rod displays a dynamic intracellular staining pattern, localizing first to kinetochores in prometaphase, but moving to kinetochore microtubules at metaphase. Early in anaphase the protein is once again restricted to the kinetochores, where it persists until the end of telophase. This behavior is in all respects similar to that described for Zw10, and suggests that the proteins function together.

Cancer treatment in rural areas

The inability to deliver cancer prevention and treatment to the rural population poses a significant barrier in the national effort to reduce cancer mortality. Since 25 percent of the U.S. population lives in rural areas and few rural areas are readily accessible to cancer centers or Community Clinical Oncology Programs (CCOPs), the prospects for accomplishing the National Cancer Institute (NCI) Goals for the Year 2000 are limited unless substantive changes occur in rural cancer care delivery. This article reviews the problem of cancer risk and care in rural areas and describes one effort to deliver state-of-the-art cancer treatment to rural patients in Virginia. It describes the needs and barriers to access in rural Virginia, the structural elements of the Rural Cancer Outreach Program, and the health policy issues that result when subspecialty care is exported to disadvantaged areas.

Percutaneous abdominal biopsy: cost-identification analysis

PURPOSE

To determine the difference in cost to providers of percutaneous abdominal biopsy as the first strategy versus surgical biopsy.

MATERIALS AND METHODS

Cost of tissue diagnosis determination with percutaneous biopsy as the first strategy in 439 patients with an abdominal mass was estimated. Costs included direct hospital costs and professional costs of initial and repeat biopsy, follow-up imaging and clinic visits, surgical biopsy (when needed), and treatment of complications. The sum of these costs was compared with the estimated cost had the same patients undergone surgical biopsy instead, with no complications or need for follow-up or repeat biopsy.

RESULTS

The total estimated cost of percutaneous biopsy as the first strategy ($543,245) was less than the cost had surgical biopsy been used alone ($1,919,867). The average per patient direct hospital cost of percutaneous biopsy ($800) was lower than that of surgical biopsy ($3,419). The average per patient professional cost of percutaneous biopsy ($438) was also lower than that of surgical biopsy ($955). Savings averaged $3,136 per patient, or $1,376,622 for the study period.

CONCLUSION

Substantial health care cost savings may result by using a diagnostic algorithm in which percutaneous biopsy is the first strategy for establishment of a diagnosis in patients suspected of having abdominal malignancy.

CARPAL TUNNEL SYNDROME IN THE MUCOPOLYSACCHARIDOSES AND MUCOLIPIDOSES

Children with a mucopolysaccharidosis or mucolipidosis suffer progressive disability of the hands, particularly in relation to dysfunction of the median nerve. This is an increasing problem because bone-marrow transplantation has dramatically improved survival without apparently changing the musculoskeletal manifestations. We have reviewed 48 children with these syndromes who required carpal tunnel decompression, recording symptoms, signs, radiological, electrophysiological and operative findings, histology and upper-limb function. In these children the carpal tunnel syndrome differs from that seen in adults. Symptoms are rare but signs such as decreased sweating, pulp atrophy, thenar wasting and manual clumsiness are much more common. At operation, the flexor retinaculum was thickened and a mass of white tenosynovium engulfed the flexor tendons. Most patients had some definite nerve constriction with a thickened epineurium.

Functional improvement was seen after early decompression, with some benefit from simultaneous tendon release. Regular physiotherapy helped to maintain increased hand movement.

We describe our assessment protocol, the physiotherapy and operative regime and the standard functional review which helps to maximise function in the hands and upper limbs of these children.

Carpal tunnel syndrome in the mucopolysaccharidoses and mucolipidoses

Children with a mucopolysaccharidosis or mucolipidosis suffer progressive disability of the hands, particularly in relation to dysfunction of the median nerve. This is an increasing problem because bone-marrow transplantation has dramatically improved survival without apparently changing the musculoskeletal manifestations. We have reviewed 48 children with these syndromes who required carpal tunnel decompression, recording symptoms, signs, radiological, electrophysiological and operative findings, histology and upper-limb function. In these children the carpal tunnel syndrome differs from that seen in adults. Symptoms are rare but signs such as decreased sweating, pulp atrophy, thenar wasting and manual clumsiness are much more common. At operation, the flexor retinaculum was thickened and a mass of white tenosynovium engulfed the flexor tendons. Most patients had some definite nerve constriction with a thickened epineurium. Functional improvement was seen after early decompression, with some benefit from simultaneous tendon release. Regular physiotherapy helped to maintain increased hand movement. We describe our assessment protocol, the physiotherapy and operative regime and the standard functional review which helps to maximise function in the hands and upper limbs of these children.

Effect of chronic resistive loading on ventilatory control in a rat model

Acute resistive loading of the airway has been shown to activate the endogenous opioid system, with subsequent depression of ventilation. The present investigation was designed to assess the effect of chronic airway loading on ventilation and CO2 sensitivity, and to determine whether the endogenous opioid system contributes to long-term modulation of ventilatory control in this setting. A flow-resistive ventilatory load was imposed in 2-mo-old rats by surgical implantation of a circumferential tracheal band that approximately tripled tracheal resistance. Respiration and CO2 sensitivity were serially and noninvasively assessed by barometric plethysmography over a period of 21 wk. Ventilatory output was assessed as minute inspiratory effort, which was defined as the product of plethysmograph signal amplitude, inspiratory time, and respiratory rate (RR). CO2 sensitivity was calculated as the percent change in minute inspiratory effort from room air to CO2 exposure. The effect of naloxone administration on these parameters was also determine. Arterial blood gases demonstrated hypercapnia with maintenance of normoxia in loaded rats; these findings persisted for the duration of the study. Two days after surgery, rats with tracheal obstruction demonstrated a lower RR than controls during room air breathing and during CO2 stimulation. CO2 sensitivity was significantly depressed in obstructed animals at this time. Escape from suppression of RR and CO2 sensitivity was evident by 14 to 21 d after obstruction; however, suppression of these parameters reappeared and was maintained from 56 to 147 d after obstruction. Naloxone augmented minute inspiratory effort during CO2 stimulation at 2 d after obstruction but not thereafter; naloxone had no effect in control rats. These data indicate that chronic airway loading suppresses RR and CO2 sensitivity in a triphasic manner. The early suppression is partially reversible by naloxone; late-appearing suppression is unaffected by naloxone and is presumably mediated by mechanisms that do not involve endogenous opioids.

Metastasis of a renal carcinoma to a cerebellar haemangioblastoma in a case of von Hippel-Lindau disease

A patient with Von Hippel-Lindau disease had a long-standing cerebellar cyst which recurred for the fifth time. At operation there was evidence of a renal carcinoma metastasis in the wall of the cyst which was probably a haemangioblastoma.

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.

Separation of beta-cells from dispersed porcine pancreas by selective lectin binding

Variation in cell-surface sugar residues which exist between different pancreatic cells has been exploited in an attempt to isolate beta-cells from dispersed porcine pancreas utilizing selective lectin binding. The binding characteristics of a range of lectins were compared to determine their ability to differentiate between endocrine and non-endocrine cells in the porcine pancreas. Histological analysis showed that peroxidase labelled Arachis hypogaea bound selectively to islet cells in Carnoy-fixed sections of pancreas. In five experiments, porcine pancreas was dispersed into single cells by collagenase digestion, incubated with fluorescein isothiocyanate-labelled Arachis hypogaea and analysed using a Fluorescence Activated Cell Sorter. Fluorescein isothiocyanate-labelled Arachis hypogaea bound to a population of cells comprising 6% +/- 4.2% (mean +/- s.d.) of the total. Cells from representative samples were sorted into populations, based on fluorescence. Immunohistochemical analysis of the fluorescent populations showed that 93% +/- 2% of these cells contained insulin: none of the cells stained positive for glucagon or somatostatin. These preliminary studies show that it is possible to separate porcine beta-cells from a dispersed cell preparation using a fluorescent labelled lectin.

Reduced tumour growth of the human colonic cancer cell lines COLO-320 and HT-29 in vivo by dietary n-3 lipids

Seventy-five nude mice received subcutaneous inoculation with 1 X 10(7) cells of the human colonic cancer cell lines COLO-320 or HT-29. Tumour growth was assessed over 4 weeks in animals given one of three iso-caloric diets; standard diet, high saturated fat (20% coconut) diet and high n-3 fat (20% Maxepa fish oil) diet. The n-3 diet produced significant tumour growth reduction compared to the other diets for COLO-320 at 3 to 4 weeks (P less than 0.05 at least) and similarly for HT-29 at 4 weeks (P less than 0.05). Significant incorporation of n-3 fatty acids occurred in red cell membranes, adipose tissue and both neutral lipid and phospholipid fractions of tumour lipids in animals fed Maxepa (P less than 0.01 at least). This was accompanied by reduction of linoleic acid and arachidonic acid in these tissues (P less than 0.01 at least) but was most marked in the metabolically labile phospholipid fraction. There was high mitotic activity in the tumours from all the groups but there was no difference according to diet.

Patterns of psychiatric morbidity in a genito-urinary clinic. A validation of the Hospital Anxiety Depression scale (HAD)

The prevalence of psychiatric disorder (by DSM-III criteria) in a population attending a genito-urinary clinic was found to be 31%. The performance of the Hospital Anxiety Depression (HAD) scale as a screening questionnaire for psychiatric disorder was assessed. Case definition by a score of 8 or more on either of the anxiety or depressive subscales produced optimal results, giving sensitivities of 82% and 70%, and specificities of 94% and 68%, for depressive and anxiety disorders respectively.

Arthroscopic subacromial decompression: results according to the degree of rotator cuff tear

We evaluated the results of arthroscopic subacromial decompression according to the degree of rotator cuff tear in 71 patients, available for follow-up for at least 1 year (average 19 months). Of the patients with stage II disease, 82% were satisfied regardless of whether they had no rotator cuff tear (nine of 11) or had a partial tear (28 of 34) of the rotator cuff. Of patients with stage III disease (complete rotator cuff tear), 88% (23 of 26) were satisfied. An acceptable objective UCLA shoulder rating greater than or equal to 28 points was seen in 82% (nine of 11) of the patients without a rotator cuff tear, 76% (26 of 34) with a partial tear, and 77% (20 of 26) with a complete tear. All four of the patients with complete tears less than 1 cm obtained excellent results. Three of the six failures were in patients with complete tears who had a narrowed acromial-humeral distance of less than 7 mm. The average UCLA pain score showed significant improvement from 2.8 (constant pain) to 8.6 (occasional pain) at 1-2 years postoperatively. The function, strength, and active forward flexion scores also increased at 1-2 years from their preoperative values. The overall patient satisfaction rate of 85% and the objective success rate of 77% are within the range of that seen with open rotator cuff repair.

[Determination of the novocaine salt of benzylpenicillin]

A simple procedure for acidometric titration of procaine benzylpenicillin after its chloroform extraction from alkaline solutions is described. Sodium benzylpenicillin does not prevent the titration.