Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence regarding risks and benefits. This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are also reviewed. Relevant articles are classified according to the Quality Standards Subcommittee classification scheme. Treatment after a first unprovoked seizure appears to decrease the risk of a second seizure, but there are few data from studies involving only children. There appears to be no benefit of treatment with regard to the prognosis for long-term seizure remission. Antiepileptic drugs (AED) carry risks of side effects that are particularly important in children. The decision as to whether or not to treat children and adolescents who have experienced a first unprovoked seizure must be based on a risk-benefit assessment that weighs the risk of having another seizure against the risk of chronic AED therapy. The decision should be individualized and take into account both medical issues and patient and family preference.

A simulated annealing approach to define the genetic structure of populations

We present a new approach for defining groups of populations that are geographically homogeneous and maximally differentiated from each other. As a by-product, it also leads to the identification of genetic barriers between these groups. The method is based on a simulated annealing procedure that aims to maximize the proportion of total genetic variance due to differences between groups of populations (spatial analysis of molecular variance; samova). Monte Carlo simulations were used to study the performance of our approach and, for comparison, the behaviour of the Monmonier algorithm, a procedure commonly used to identify zones of sharp genetic changes in a geographical area. Simulations showed that the samova algorithm indeed finds maximally differentiated groups, which do not always correspond to the simulated group structure in the presence of isolation by distance, especially when data from a single locus are available. In this case, the Monmonier algorithm seems slightly better at finding predefined genetic barriers, but can often lead to the definition of groups of populations not differentiated genetically. The samova algorithm was then applied to a set of European roe deer populations examined for their mitochondrial DNA (mtDNA) HVRI diversity. The inferred genetic structure seemed to confirm the hypothesis that some Italian populations were recently reintroduced from a Balkanic stock, as well as the differentiation of groups of populations possibly due to the postglacial recolonization of Europe or the action of a specific barrier to gene flow.

Relaxation and dephasing of multiexcitons in semiconductor quantum dots

We measure the dephasing time of ground-state excitonic transitions in InGaAs quantum dots under electrical injection in the temperature range from 10 to 70 K. Electrical injection into the barrier region results in a pure dephasing of the excitonic transitions. Once the injected carriers fill the electronic ground state, the biexciton to exciton transition is probed and a correlation of the exciton and biexciton phonon scattering mechanisms is found. Additional filling of the excited states creates multiexcitons that show a fast dephasing due to population relaxation.

T cell reactivity against the SmD1(83-119) C terminal peptide in patients with systemic lupus erythematosus

BACKGROUND

The SmD1(83-119) peptide is a major target of the B cell response in patients with systemic lupus erythematosus (SLE).

OBJECTIVE

To investigate the T cell response directed against this peptide, its disease specificity, and possible impact on SLE pathogenesis.

METHODS

Peripheral blood mononuclear cells derived from 28 patients with SLE and 29 healthy and disease controls were stimulated by the SmD1(83-119) and the recombinant (r)SmD1 protein, and [3H]thymidine incorporation was measured. Patients with SLE were simultaneously tested for autoantibodies, disease activity, clinical symptoms, and medical treatments.

RESULTS

T cell reactivity against the SmD1(83-119) peptide was detected in 11/28 (39%) patients with SLE and against the rSmD1 protein in 10/28 (36%) patients. In contrast, only 2/29 (7%) controls exhibited SmD1 reactivity. An analysis of proliferation kinetics showed that SmD1 reactive T cells are activated in vivo, as additionally confirmed by cytometric analysis. Addition of mammalian dsDNA to rSmD1 enhanced the rSmD1-specific T cell response. SmD1(83-119)-specific T cell reactivity was significantly more common in patients with cardiac and pulmonary symptoms. No correlation between T and B cell responses and disease activity was seen.

CONCLUSION

SmD1(83-119) is a major T cell epitope of SmD1, commonly recognised by T cells from patients with SLE and much less commonly found by healthy or disease controls. This strong T cell reactivity as well as the high frequency and specificity of anti-SmD1(83-119) antibodies in SLE suggest a possible role in SLE pathogenesis, at least in a subset of patients.

Swelling of cross-linked polyelectrolyte gels

A model of a cross-linked polyelectrolyte gel has been examined using Monte Carlo simulations. The simple model contained a charged defect-free network represented by linked charged beads and explicit counterions. Pressure-density relations for the polyelectrolyte gel, a corresponding non-ionic polymer gel, and several partly or fully degraded gels have been determined. The polyelectrolyte gel displayed a very large swelling capacity, in agreement with experiments. The swelling mechanism and chain properties are discussed and foundations of current theories on gel swelling are examined.

Acquisition of a sensorimotor skill in younger and older adults

The present study compared the learning of sensorimotor transformation rules in young and elderly subjects. In a first experimental session, participants executed manual tracking movements first under normal, and then under left-right reversed visual feedback. Overall, seniors' tracking performance was lower. However, both age groups responded in a quantitatively similar way to the feedback change: Tracking errors increased by a similar amount at the onset of left-right reversal, and then gradually returned to the respective baseline levels. In a second session, visual up-down reversal was added to the left-right reversal. The initial increase of tracking error was substantially smaller than in the first session, and this benefit was even more pronounced in seniors. We interpret the benefit of the second session as learning-to-learn, i.e., as enhancement of a general ability to learn new skills, and conclude that in our study, learning-to-learn was more pronounced in elderly subjects.

Prospective cross-sectional study of haemostatic factors in patients with and without coronary artery disease

The role of haemostatic factors for arterial thrombosis, especially the prevalence of activated protein C (APC) resistance in patients with coronary artery disease (CAD), is controversial. Between November 1996 and August 1997, 665 patients were analyzed. Diagnosis of CAD was confirmed by coronary angiography, exclusion of CAD was accepted in the presence of negative stress testing or a negative coronary angiography. CAD was present in 370 (56%) and excluded in 295 (44%) patients. Patients with CAD were older (64 +/- 9.2 versus 57.7 +/- 16 years; P <or= 0.001), more often male [74.1 versus 48.5%; odds ratio (OR) = 3.0, 95% confidence interval (CI) = 2.2-4.2] and had a higher body mass index (27.2 +/- 3.6 versus 26 +/- 4.3; P <or= 0.001). Most conventional risk factors showed a higher prevalence in patients with CAD. An APC ratio < 2.0 showed a tendency towards a higher prevalence in patients with CAD (10.5 versus 6.4%; OR = 1.7, 95% CI = 1.0-3.0). This difference was significant in men (11.7 versus 4.2%; OR = 3.0, 95% CI = 1.3-7.1), but not in women (7.3 versus 8.6%; OR = 0.8, 95% CI = 0.3-2.2). Multiple logistic regression analysis showed an independent association of the presence of CAD with age, male gender, current smoking, arterial hypertension, lipoprotein(a) levels and an APC ratio < 2.0 (OR = 2.87, 95% CI = 1.08-8.12). APC resistance with an APC ratio < 2.0 was the only haemostatic factor that was independently associated with the presence of CAD. This association was significant only for men. It may indicate a contribution of the APC resistance to the development of CAD, which has to be proven by the follow-up.

[Use of heparin in acute myocardial infarction in routine clinical practice in Germany. Results of the MITRA and MIR registries]

OBJECTIVE

Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today.

METHODS

MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22,697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy.

RESULTS

21,004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p = ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p < 0.001).

CONCLUSIONS

Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only slightly higher than reported in randomized trials.

Transmission of hepatitis A in hamburg, germany, 1998-1999--A prospective population based study

To study the pattern of transmission of HAV in a large urban community a prospective cohort study was conducted in Hamburg between 1 January 1998 and 31 December 1999. Four hundred and eleven patients were classified as hepatitis A cases comprising 144 foreign and 267 German persons. Univariate analyses were carried out to examine differences between socio-demographic, clinical and behavioural characteristics. To determine independent predictors for HAV infection a multiple logistic-regression model was used. The principal risk factor was travel to areas where hepatitis A is endemic, with 32.6% (n= 134/411) of all documented cases of hepatitis A. Foreign patients who had acquired the infection abroad, mostly children, accounted for the majority of these cases. Of all 411 cases, 42 (10.2%) were associated with parenteral drug, followed by day-care or school contact (8.3%; n = 34). Outbreaks contributed to 11.4% of cases (n = 47), but only 7.1% (n = 29) were household contacts. The low incidence rate among exposed persons in the households of those infected was similar in the groups of foreign and German nationals (17/384 = 4.4% and 12/231 = 5.2%, respectively), which may demonstrate a good hygienic level in general. Our findings suggest that preventive measures such as the improvement of hygienic conditions in a defined general population may contribute to a reduced incidence of hepatitis A. Nevertheless, because hygienic standards may change with time, this policy should be supplemented by targeted vaccination of groups at risk.

[Long-term follow-up of patients with acute myocardial infarction treated with primary angioplasty or thrombolysis. Results of the MITRA trial]

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.

Synthesis of adducts with amino acids as potential dosimeters for the biomonitoring of humans exposed to toluenediisocyanate

Toluenediisocyanates (TDI) are important intermediates in the chemical industry. Among the main damages after low levels of TDI exposure are lung sensitization and asthma. Protein adducts of TDI might be involved in the etiology of sensitization reactions. Blood protein adducts are used as dosimeters for modifications of macromolecules in the target organs where the disease develops. The functional groups of cysteine, tyrosine, serine, lysine, tryptophan, histidine, and N-terminal amino acids are potential reaction sites for isocyanates. Especially the N-terminal amino acids, valine, and aspartic acid of hemoglobin and albumin, respectively, are reactive toward electrophilic xenobiotics. To develop methods for the quantitation of protein adducts of 2,4- and 2,6-TDI, we reacted 3-nitro-4-methylphenyl isocyanate (1a) with single amino acids and reduced the nitro group using catalytic hydrogenation or ammonium formate with palladium on carbon yielding N-[(3-amino-4-methylphenyl)carbamoyl]valine (2a), N-[(3-amino-4-methylphenyl)carbamoyl]aspartic acid (8a), N(alpha)-acetyl-N(epsilon)-[(3-amino-4-methylphenyl)carbamoyl]lysine (12a), and N(alpha)-acetyl-O-[(3-amino-4-methylphenyl)carbamoyl]serine (15a). The same reactions were performed with 5-nitro-2-methylphenyl isocyanate (1b) and 3-nitro-2-methylphenyl isocyanate (1c). The valine adducts were boiled in acid to obtain the corresponding hydantoins: 3-(3-amino-4-methylphenyl)-5-isopropylimidazoline-2,4-dione (5a), 3-(5-amino-2-methylphenyl)-5-isopropylimidazoline-2,4-dione (5b), and 3-(3-amino-2-methylphenyl)-5-isopropylimidazoline-2,4-dione (5c). A method for the detection of N-terminal adducts with valine in biological samples was developed. The tripeptide adduct N-[(3-amino-4-methylphenyl)carbamoyl]valyl-glycyl-glycine (19a) was hydrolyzed with acid in the presence of globin and the internal standard N-[(3-amino-4-methylphenyl-d(6))carbamoyl]valyl-glycyl-glycine (19d). The released hydantoins were determined by LC/MS/MS and after derivatization with pentafluoropropionic anhydride by GC/MS. The determination limit was 0.16 pmol/sample. The same N-terminal adduct with valine was found in globin of a TDI-worker and in two women with polyurethane covered breast implants.

Application of SERS spectroscopy to the identification of (3,4-methylenedioxy)amphetamine in forensic samples utilizing matrix stabilized silver halides

A method based on surface-enhanced Raman scattering (SERS) spectroscopy was developed to meet the need for the reliable and rapid identification of illicit drugs such as the 'designer drug' XTC, preferably to increase the security of legal certificates. A matrix stabilized silver halide dispersion on a microtiter plate is used as the SERS-active substrate, providing an easy to use system for sample preparation and probing by means of a Raman microscope. The potential of the method is demonstrated by applying it to the identification of the psychoactive ingredients of drug containing tablets which were confiscated by the local police at techno-music events. The samples of interest were 26 different brands of XTC tablets and several pieces of evidence (powders) containing amphetamine. For reference, we show SERS and Raman spectra of pristine amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine, 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyethamphetamine.

[Synaesthesia - towards a cognitive neuroscience of coloured hearing]

This review is about synaesthesia, a well known but still poorly investigated phenomenon. The most common form of synaesthesia is coloured hearing. Epidemiological and genetical studies show that synaesthesia has a higher prevalence in the normal population than previously stated. Most subjects are female and there is a clear heritability. Psychophysical investigations of synaesthetic mechanisms in normal subjects show reliable colour-tone-attributions. Single case studies with paradigms from experimental psychology found a high consistency of synaesthetic associations and observed behaviourally relevant interferences between primary perception and secondary synaesthetic sensations. The first studies using functional neuroimaging methods found specific neuronal correlates of synaesthesia. Neuropsychiatric studies analyze synaesthesia-like phenomena in patients with optical nerve lesions, upper limb amputation or severe depression and as induced by hallucinogenic drugs. Data-based and more speculative theories and models of synaesthesia are presented and critically discussed.

Rochester, New York: a decade of emergency department overcrowding

Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization. Overcrowding in EDs was severe in the late 1990s-2000, and became an accepted local standard of care.

OBJECTIVE

To study the strategies to reduce ED overcrowding in Rochester in the last decade.

METHODS

A descriptive analysis of individual hospital and community efforts to decrease ED overcrowding.

RESULTS

Of the strategies tried, those that had little effect on ED overcrowding were based from the ED, such as ambulance diversion. Those that were successful were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; a transition team (mid-level provider along with registered nurse (RN)/licensed practical nurse) who cared for inpatients boarded in the ED; integrated services across affiliated hospitals/systems; an early alert system that notified key personnel before "code red" criteria were met; and a multidisciplinary team to round in the ED and analyze resource needs. Current community-wide initiatives include precise tracking of code red hours; monitoring patient length of stay (LOS) in the ED and inpatient units; education of physicians and nursing homes regarding ED alternatives; exploration of additional resources for subacute and long-term care; establishing a regional forum to address the nursing shortage; development of an ED triage system to coordinate diversion activities during code red; and consideration of a county-wide state of emergency when needed.

CONCLUSIONS

Emergency department overcrowding is the end result of a variety of factors that must be addressed system-wide.

Pharmacokinetics of two oral prednisolone tablet formulations in healthy volunteers

Two prednisolone (CAS 50-24-8) formulations (Prednisolone 50 mg Ferring tablets as the test preparation and tablets of a reference preparation) were investigated in 13 healthy volunteers in order to prove bioequivalence between these preparations. A single oral dose of 50 mg was given using a randomized, two-way cross-over design with a wash-out period of one week. Blood samples for determination of prednisolone plasma concentrations were collected up to 15 h following drug administration. Additionally, in vitro tests were performed with tablets from the same lots to determine dissolution characteristics. Prednisolone concentrations were measured by means of validated HPLC with UV-detection. Maximum concentrations (Cmax) of 1020.9 +/- 57.8 and 1053.3 +/- 55.7 ng/ml were achieved for the test and the reference preparation, respectively. The AUC0-infinity was 212.2 +/- 13.2 micrograms.min/ml (test preparation) and 222.2 +/- 14.3 micrograms.min/ml (reference preparation). The 90% confidence intervals of the test to reference ratios were within the range of 80-125% with 97.8-101.3% for Cmax and 98.1-100.4% for AUC0-infinity. The time to reach maximum plasma concentration (tmax) tended to be lower (-25%) in the test (39.6 +/- 6.4 min) as compared to the reference preparation (52.8 +/- 9.0 min). Interestingly, this difference correlated well with the observation of a more rapid dissolution rate of the test preparation by some 10 min. Both prednisolone formulations were well tolerated. Based on the results obtained in this study, (1) bioequivalence between the test and the reference preparation was clearly demonstrated and (2) a positive correlation between dissolution rate observed in vitro and tmax as measured in vivo was found.

Case report. Mycotic arteritis due to Aspergillus fumigatus in a diabetic with retrobulbar aspergillosis and mycotic meningitis

A 74-year-old man with diabetes mellitus type II, retinopathy and polyneuropathy suffered from exophthalmus, ptosis and diplopia. Magnetic resonance imaging and computer tomography showed a space-occupying process in the right orbital apex. An extranasal ethmoidectomy accompanied by an orbitotomia revealed the presence of septated hyphae. Aspergillus fumigatus was grown from the tissue. After surgical removal of the fungal masses, therapy with amphotericin B (1 mg kg(-1) body weight) plus itraconazole (Sempera, 200 mg per day) over 6 weeks was initiated. Five months later the patient's condition deteriorated again, with vomiting, nausea and pain behind the right eye plus increasing exophthalmus. Antifungal therapy was started again with amphotericin B and 5-fluorocytosine. Neutropenia did not occur. The patient became somnolent and deteriorated, a meningitis was suggested. Aspergillus antigen (titre 1:2, Pastorex) was detected in liquor. Anti-Aspergillus antibodies were not detectable. Both the right eye and retrobulbar fungal masses were eradicated by means of an exenteratio bulbi et orbitae. However, renal insufficiency and an apallic syndrome developed and the patient died. At autopsy, a mycotic aneurysm of the arteria carotis interna dextra was detected. The mycotic vasculitis of this aneurysm had caused a rupture of the blood vessel followed by a massive subarachnoidal haemorrhage. In addition, severe mycotic sphenoidal sinusitis and aspergillosis of the right orbit were seen, which had led to a bifrontal meningitis.