[Predictive value of rapid tests of cognitive condition in traumatic head injury]

INTRODUCTION

Neuropsychological assessment after head injury (HI) is sometimes not possible because of the physical and/or cognitive condition of the patient, or the lack of neuropsychological specialists at the hospital. Therefore clinical scales and rapid tests are used to obtain information about the severity of the lesion and the general cognitive condition.

OBJECTIVE

To determine whether the rapid clinical scales used to assess the severity of HI (Glasgow Coma Scale, GCS), presence or absence of post-traumatic amnesia (Galveston Orientation and Amnesia Test, GOAT) and general cognitive condition (Mini-Mental State Examination, MMSE, and Short Test of Mental Status, STMS) predict the cognitive condition one year after the head injury.

PATIENTS AND METHODS

We made a prospective, longitudinal, observational study of 100 persons of both sexes with HI, assessed on admission by the Neurosurgical Department, and one year after the trauma in the Outpatient Clinic. Clinical scales were used to assess the severity of HI, cognitive screening tests, neuropsychological attention, linguistic, memory and practical constructive tests were also done. Statistical analysis was by simple regression.

RESULTS

The GCS only explained a small percentage of the results obtained for immediate memory. The GOAT predicted the linguistic and verbal memory test performance. The MMSE and STMS explained a high proportion of the execution of neurophychological tasks (attention, linguistic, memory and practical construction) one year after the trauma.

CONCLUSIONS

With the MMSE and STMS valid results may be obtained when it is not possible to carry out general neuropsychological assessment.

[Thalamic hematomas: etiology, clinical findings and prognosis]

INTRODUCTION

The appearance of new neuroimaging techniques has permitted study of large series of thalamic hematomas, amongst which differences have been observed according to the size and arterial territory affected.

OBJECTIVE

To determine the existence or not of differences between thalamic hematomas, according to their arterial territory and size, with regard to the aetiology, clinical findings and short term prognosis.

PATIENTS AND METHODS

A retrospective study was made of 60 patients admitted to hospital with the diagnosis of thalamic hematoma (between January 1987 and July 1997) classified according to localization as: anterior, dorsal, posterolateral, posteromedial and global, and according to size as: large (> 20 mm), and small (< 20 mm) in which we analyzed the aetiology, clinical signs and prognosis up to discharge from hospital.

RESULTS

The commonest aetiology was found to be arterial hypertension (60%); with regard to the arterial territory involved we have observed different clinical and prognostic features but the number of patients in each group was too small to permit statistical analysis. Significant differences were shown with regard to the size of the hematoma: large hematomas more often extended to nearby structures, caused hydrocephalia, were associated with alteration in the level of consciousness, severe motor deficit, oculomotor changes, alteration in superior functions and hemianopsia, and had worse prognosis and increased mortality and dependence in everyday activity than small hematomas.

CONCLUSION

According to their size, thalamic hematomas show statistically significant clinical and prognostic differences.

[Functional prognosis of stroke patients after 3 months: determining factors]

OBJECTIVE

To analyze the factors involved in the functional prognosis of stroke patients three months after onset.

PATIENTS AND METHODS

We made a prospective study of 288 patients with non-transient strokes who had been admitted consecutively to our hospital. Data was collected on a standardized questionnaire: age, sex, risk factors, latency of admission, interval of neurological attention (INA), severity of defect (classified on the Scandinavian scale: slight-moderate: SSS > 30/serious: SSS < or = 30), stay in hospital, development of complications and previous quality of life, after seven and ninety days. Two groups were considered according to Barthel's index (BI): acceptable recuperation: BI > 60 and poor recuperation BI < or = 60.

RESULTS

The average age was 70.72 years and the latency of admission was 9.71 hours. After three months the functional prognosis was good in 145 patients. On bivariate analysis the latency of admission, severity of the stroke, age, development of complications, INA and BI, one week later were significant. Multivariate analysis confirmed as independent indicators of poor prognosis after 90 days: advanced age of the patient (p = 0.006), the development of complications (p = 0.0235), serious neurological defect (p = 0.0274) and the BI after seven days (p = 0.006).

CONCLUSIONS

Advanced age of the patient, the extent of the defect and appearance of complications whilst in hospital were associated with poorer quality of life after three months. The INA > 6 hours also had a negative influence, although it was not confirmed to be an independent variable.

Enteric bacterial catalysts for fuel ethanol production

The technology is available to produce fuel ethanol from renewable lignocellulosic biomass. The current challenge is to assemble the various process options into a commercial venture and begin the task of incremental improvement. Current process designs for lignocellulose are far more complex than grain to ethanol processes. This complexity results in part from the complexity of the substrate and the biological limitations of the catalyst. Our work at the University of Florida has focused primarily on the genetic engineering of Enteric bacteria using genes encoding Zymomonas mobilis pyruvate decarboxylase and alcohol dehydrogenase. These two genes have been assembled into a portable ethanol production cassette, the PET operon, and integrated into the chromosome of Escherichia coli B for use with hemicellulose-derived syrups. The resulting strain, KO11, produces ethanol efficiently from all hexose and pentose sugars present in the polymers of hemicellulose. By using the same approach, we integrated the PET operon into the chromosome of Klebsiella oxytoca to produce strain P2 for use in the simultaneous saccharification and fermentation (SSF) process for cellulose. Strain P2 has the native ability to ferment cellobiose and cellotriose, eliminating the need for one class of cellulase enzymes. Recently, the ability to produce and secrete high levels of endoglucanase has also been added to strain P2, further reducing the requirement for fungal cellulase. The general approach for the genetic engineering of new biocatalysts using the PET operon has been most successful with Enteric bacteria but was also extended to Gram positive bacteria, which have other useful traits for lignocellulose conversion. Many opportunities remain for further improvements in these biocatalysts as we proceed toward the development of single organisms that can be used for the efficient fermentation of both hemicellulosic and cellulosic substrates.

Proportion of S-phase tumor cells measured by flow cytometry is an independent prognostic factor in meningioma tumors

Meningiomas are tumors in arachnoid cells which represent up to one fifth of all intracranial tumors and up to a quarter of spinal neoplasias. Although meningiomas have classically been considered to be benign tumors, it has also been well-established that they show a heterogeneous clinical outcome. To the best of our knowledge no study has yet been performed in which the independent prognostic value of both DNA ploidy and cell cycle has been simultaneously assessed in a large series of meningioma tumors. The aim of the present study was to prospectively explore the prognostic value of DNA ploidy status and the proliferative rate of tumor cells in a series of 105 consecutive meningioma patients studied at diagnosis. Both the presence of DNA aneuploidy and the proportion of S-phase tumor cells were analyzed in all cases in fresh tumors obtained during diagnostic surgery. From the technical point of view, we followed the recommendations of the Consensus Conference on Flow Cytometry DNA Analysis held in October 1992. Our results show that meningioma tumors display a relatively low incidence of DNA aneuploidy (14%), and they usually show a low proliferative rate (mean percentage of S-phase cells of 1.3 +/- 0.3%). The presence of DNA aneuploidy was associated with a higher incidence of aggressive histopathologic subtypes (P = 0.045), a greater age (P = 0.009), location at the cerebral convexity (P = 0.004), and a greater proportion of S-phase cells (P = 0.005). In contrast, no significant association between the DNA ploidy status of meningioma patients and their disease-free survival was found (P = 0. 1). Regarding the proliferative activity of neoplastic cells, we found that a high proportion of S-phase cells (>1.8%) was associated with a significantly lower mean age (P = 0.007), aggressive histopathologic subtypes (P = 0.03), a higher incidence of DNA aneuploidy (P = 0.004), and a significantly shorter disease-free survival (P < 0.004). Multivariate analysis of prognostic factors showed that the proportion of S-phase tumor cells was the most powerful independent prognostic factor in meningioma patients (P = 0.02). In summary, we conclude that the proportion of S-phase tumor cells represents the individual parameter with the highest value for predicting disease-free survival in meningioma patients.

[Diagnostic decision tree for the correct use of neuropsychological evaluation in head injury]

INTRODUCTION AND OBJECTIVE

We present a diagnostic decision tree for the correct use of neuropsychological evaluation techniques in head injury. Our aim is to avoid extensive, intensive use of unnecessary tests and measurements or lapses into diagnostic error which often accompany cognitive dysfunction when 'superficial' 'undirected' studies are done.

DEVELOPMENT

It is essential to select the neuropsychological, neuroconductal and psychosocial evaluation tests which are most suitable in each case and establish a reliable diagnosis of the functional, cognitive, emotional and psychosocial conditions of the patient. The decision tree for neuropsychological evaluation is a guide to assist professionals so that they may adequately examine the functional changes which can occur as a consequence of traumatic brain damage, adapted to each point in its evolution and taking into account factors which may influence neuropsychological evaluation.

CONCLUSION

The evaluation of consequences of trauma includes evaluation of the gravity of the head injury, and the neuropsychological, neuroconductal and functional evaluation of the patient.

[Spanish study of quality of life in migraine (II). Profile of medication consumption and subjective efficacy]

OBJECTIVES

The response to the different antimigraine medications is variable. In this study we have analysed the profile of prescription of these antimigraine medications, both preventive and symptomatic, by a group of spanish neurologists and examined the subjective efficacy of these compounds.

PATIENTS AND METHODS

Neurologists from 7 hospitals in different spanish regions interviewed 305 patients (at least 40 per hospital) who met migraine diagnostic criteria. They used an ad hoc questionnaire in which the antimigraine medications, both symptomatic and preventive, taken by the patients, as well as their subjective response were registered. Patients with transformed migraine or tension-type headache more than 2 days per week were excluded.

RESULTS

Analgesics, non-steroidal anti-inflammatory drugs, ergotics and sumatriptan had been taken by 99, 69, 54 and 40% of the 305 interviewed patients, respectively. A subjective good response was refered to by 9% of patients who had taken analgesics, 23% of patients who had taken non-steroidal anti-inflammatory drugs, 39% of those who had taken ergotics and 63% of patients with sumatriptan. The current symptomatic treatment was: analgesics 34% of cases, non-steroidal anti-inflamatory drugs 26%, ergotics 13% and sumatriptan 63%. Regarding preventive treatments, 108 patients (35%) had been treated with calcium-antagonists, 87 (29%) with beta-blockers, 55 (18%) with amitriptyline and only 7 (2.2%) with valproic acid. The percentages of good responses to these drugs were: 55% for beta-blockers, 42% for calcium-antagonists and 31% for amitriptyline.

CONCLUSIONS

Our data confirm that analgesics are not efficacious in the majority of migraine patients and that the advent of sumatriptan has clearly improved the quality of migrane symptomatic treatment, even though about one-third of migraine patients do not respond to this drug. This study confirm that calcium-antagonists are the antimigraine preventive treatment most frequently prescribed in our country, even though their subjective efficacy is lower than that of beta-blockers.

[Symptomatic epilepsy: review of 208 patients]

OBJECTIVE

To determine the main etiological mechanisms of symptomatic epilepsy and its frequency according to age.

PATIENTS AND METHODS

We made a retrospective analysis of 208 patients admitted during a period of four and a half years, studying the variables: age, sex and type of seizures: simple partial, secondarily generalized partial, complex partial, tonic-clonic, generalized tonic, and also EEG and neuroimaging.

RESULTS

The main etiological mechanisms found were: vascular (31.25%), alcoholic (12.01%), intracranial disorders (9.61%), traumatic (5.28%), degenerative (5.28%), infectious (2.88%) and cryptogenic (33.65%). In the last group there was an outstandingly large proportion of patients with silent infarcts. When considering vascular epilepsy, those seizures occurring during the acute phase of the stroke (24/65) are differentiated from those of late onset (41/65). In the latter there was a marked predominance of ischemic etiology (48.78% corresponded to extensive infarcts in the territory of the middle cerebral artery; 36.58% were associated with partial infarcts) probably because of the greater frequency of ischemic stroke as compared with hemorrhagic stroke. After the acute phase, the latency was of 10.68 +/- 0.43 months and the most frequent seizures were tonic-clonic (48.78%).

CONCLUSION

In persons under 30 years of age, etiology is multifactorial; between 30 and 50 years of age alcoholic epilepsy (39.53%) and traumatic epilepsy (11.62%) predominate; over the age of 50 years the cause was vascular in 43.5%. In the latter age group there was a high proportion of patients with heraldic seizures.

Treatment of a Giant Aneurysm of the Right Middle Cerebral Artery with GDCs after Extracranial to Intracranial Bypass. A Technical Case Report

SUMMARY

A case of a giant aneurysm of the right middle cerebral artery treated with Guglielmi detachable coils is reported. Extracranial to intracranial bypass had previously been performed and surgical trapping had been attempted. During the endovascular procedure, balloon test occlusion of the middle cerebral artery was performed in order to demonstrate clinical and angiographic tolerance to parent vessel occlusion. A previous occlusion test in the right common carotid artery did not show sufficient flow through the bypass to perform safe parent vessel occlusion. Diagnostic imaging, the endovascular procedure, and haemodynamic aspects in cases in which parent vessel occlusion is required after extracranial-intracranial bypass are described and the literature is reviewed.

Reversible peripheral neuropathy induced by a single administration of high-dose paclitaxel

Peripheral neuropathy (PN) is the main side effect with cycles of paclitaxel at standard doses (175 mg/m2 for 21 days). Administration of a single high-dose paclitaxel (HDP) is a novel approach for the treatment of cancer. We have prospectively measured neurotoxicity induced by HDP during a phase I trial. Nineteen patients were treated with escalating doses of paclitaxel by 24-hour infusion. In our study, PN induced by HDP was moderate, reversible, and not dose limiting. Severe PN was seen in patients who had received previous neurotoxic chemotherapy, and caution on the administration of HDP in this setting is warranted.

[Spanish study of quality of life in migraine (I). Profile of the patient with migraine attending neurology clinics]

BACKGROUND

Migraine is the main reason for neurological consultation.

OBJECTIVES

To analyse the profile of the patient with migraine attending the Neurological Services of our country.

PATIENTS AND METHODS

Neurologists from 7 hospitals in different spanish regions interviewed 305 patients (at least 40 per hospital) who met migraine diagnostic criteria. They used an ad hoc questionnaire in which detailed demographic and migraine clinical data were included. Patients with transformed migraine or tension-type headache more than two days per week were excluded.

RESULTS

The majority (82%), were women, with no other diseases, with an average social (88%) and cultural (41%) level. The mean age at consultation was 38 +/- 11 years, while the mean duration of migraine history was 18 +/- 13 years; 78% met criteria of migraine without aura, 15% of migraine with aura and the remaining (8%) both migraine with and without aura criteria. Main subjective precipitating factors were: stress (80%), foods (68%), drugs (34%), alcohol (20%) and menstruation (8%). Migraine pain was referred to as mild by 4% of cases, as moderate by 59% and as severe in the remaining 37%. The usual duration of migraine attacks ranged from 12 to 24 h in 35% of cases, from 24 to 48 h in 25%, from 4 to 12 h in 23% and was longer than 48 h in the remaining 17%. More than half (53%) had more than 3 attacks per month. The pain was unilateral in 70% of cases, and more than half had vomiting (57%) and sono and/or photophobia (97%).

CONCLUSIONS

The typical profile of the migraine patient attending the Neurology Services in Spain is that of a woman aged from 20-50, with a long personal history of migraine, otherwise healthy and with an average socioeconomic and cultural level. Our data confirm that migraine attacks are incapacitating in a relevant number of these patients.

[Response to treatment of chronic daily headache with analgesic abuse]

The overuse of analgesics in patients with chronic daily headache (CDH) perpetuates and worsens the headache. The aim of this study was to evaluate the clinical response to withdrawal of analgesics and to preventive treatment in a group of patients with CDH. Eighty-four patients who were taking daily symptomatic medications, and suffering from CDH were studied. Treatment consisted of withdrawal of daily symptomatic medications and prophylactic therapy. Improvement was considered when intensity and frequency of the headache were reduced more than 50%. After a 2-15 months follow-up, 57 of the 76 patients that continued in the study had improved. From these, 98% had reduced the consumption of analgesics below the figures considered as abuse and a 94% took the prophylactic medications correctly. After giving up the preventive treatment, 26% of the patient presented CDH and the 60% overuse again of analgesics. These results show that withdrawal of analgesics is necessary for improvement in patients with CDH, but the possibility of relapses is elevated. We think that there are other factors implicated in the development of CDH. We therefore believe that in order to avoid the relapses this group of patients need follow-up and preventive treatments during long periods of time.

[Mitochondrial respiratory chain deficiency may present as multiple sclerosis]

Defects of the mitochondrial respiratory chain are associated with a great variety of clinical disorders. In addition to the well recognized syndromes, a significant number of patients present non-specific encephalopathic disorders. In consequence these types of mitochondrial disorder are very difficult to diagnose on clinical features alone. In this paper, we describe the clinical and the magnetic resonance findings of 2 patients with a neurological syndrome indistinguishable from multiple sclerosis (Poser). Muscle biochemistry revealed defect of complex IV of the respiratory chain. We think that these patients have a mitochondrial encephalomyopathy. We suggest that in patients presenting as atypical multiple sclerosis it could be necessary investigating mitocondrial encephalopathy.

[Evaluation study of the chronic headache questionnaire]

INTRODUCTION

Semi-structured questionnaires, based on clinical criteria are used in the diagnosis of headache, but none has been used to study the two commonest types of chronic headache. The first step, before clinical application, is to carry out a study of the questionnaire's validity and predictive value.

OBJECTIVE

The objectives of our study were to evaluate the validity and determine the effectiveness of the ZZA questionnaire in the differential diagnosis between transformed migraine (TM) and chronic tension headache (CTH), in a specialist Neurology Clinic.

MATERIAL AND METHODS

The ZZA questionnaire, elaborated by one of the investigators, was made up of 20 questions aimed at TM, CTH or the chronicity of the headache. An observer, who did not know the diagnosis, gave the questionnaire to patients who had previously been diagnosed by the head of the Headache Clinic as having TM or CTH. The process of validation of the questionnaire consisted in showing that it was reliable, with valid contents and valid criteria.

RESULTS

On analysis of reliability, the items ZZA1, ZZA15, ZZA16 and ZZA18 gave the highest indices. The Cochran Q test showed lack of uniformity of replies. Only ZZA1, ZZA15 and ZZA18 were predictive items showing MT. None of the questions to show CTH were predictive. After final adjustment the definitive model was made up of ZZA1, ZZA15 and ZZA18.

CONCLUSIONS

The proposed questionnaire was not found to be useful for differential diagnosis between TM and CTH. Only 3 of the 20 questions were accepted as having some degree of validity and effectiveness. Two of these 3 questions, based on clinical impressions of the author, might well be included in the diagnostic criteria of TM.

[Mandibular neuropathy due to infiltration of the Gasser ganglion]

INTRODUCTION

The numb chin syndrome is characterized by oral and facial numbness restricted to the distribution of the mental nerve. This uncommon neuropathy has been described in association with a number conditions including malignant disease even in the patients no known to have cancer. Numb chin syndrome may be caused by metastatic involvement of the mental nerve, by involvement of the proximal mandibular root at the base of the skull or by intracranial leptomeningeal spread.

CLINICAL CASE/DISCUSSION

We described a case of neuropathy of the chin as the initial symptom of the breast cancer. We suggested that the lesion was in the trigeminal ganglion based on enlargement and gadolinium enhancement of the trigeminal ganglia on MRI. A mental neuropathy should initiate a search for cancer that includes MRI of the head.

[Clinical features of daily chronic headache]

INTRODUCTION

Although the International Headache Society considers chronic tension headache to be a chronic headache, patients with daily chronic headache may have pain which is not only due to tension but also has migrainous features.

OBJECTIVE

To evaluate the clinical differences and abuse of drugs in a group of patients with chronic daily headache who were consecutively evaluated in the Neurology Clinic.

MATERIAL AND METHODS

We consider the patients to have daily chronic headache when they have had pain at least 6 days a week for the past 6 months. Using this criterion, we studied 112 patients, of whom 90 (80.4%) were women and 22 (19.6%) men. Results. Sixty nine (61.6%) had transformed migraine and 43 (38.4%) tension headache. There were no differences in their current ages but the age of onset of the headaches varied (p = 0.000,t). Unilateral pain, trigger factors and a family history were more frequent in the cases of transformed migraine. Eighty four patients (75%) abused analgesics. Although we found different pain intensities (p = 0.000, chi 2) there was no difference in the weekly consumption of analgesics (p = 0.64, t) in the mg/week of ergotamine (p = 0.96, t) nor in absence from work between the two types of headache.

CONCLUSIONS

In spite of clinical differences between transformed migraine and tension headache, which may help diagnosis, in our series abuse of analgesics (including ergotamine) was a common characteristic.

Relationships of C-peptide levels and the C-peptide/bloodsugar ratio with clinical/biochemical variables associated with insulin resistance in orally-treated, well-controlled type 2 diabetic patients

The aim of the present study was to evaluate the relationship of C-peptide and the C-peptide/bloodsugar ratio with clinical/biochemical variables presenting a well-known association with insulin resistance in NIDDM patients in acceptable control, obtained without the use of exogenous insulin. A total of 118 non insulin dependent diabetes mellitus (NIDDM) patients treated with diet/oral drugs and having a HbA(1c) level < 7.5% have been studied. Non-stimulated C-peptide levels (RIA) and the C-peptide/bloodsugar ratio have been determined and their relationships with the blood pressure status, blood pressure figures, estimates of adiposity, age, known duration of diabetes, current therapies, plasma lipids, glycaemic control, urinary albumin excretion rate, uric acid and creatinine have been ascertained. C-peptide levels were significantly (P < 0.05) correlated with systolic (r = 0.21) and diastolic blood pressure (r = 0.19), BMI (r = 0.21), high density lipoprotein (HDL) (r = -0.22), non-HDL-cholesterol (r = 0.23), apolipoprotein B (r = 0.29), log of triglycerides (r = 0.39) and uric acid (r = 0.35). The C-peptide/bloodsugar ratio had statistically significant correlations with known duration of diabetes (r = -0.23), diastolic blood pressure (r = 0.21), body mass index (BMI) (r = 0.22), log of triglycerides (r = 0.23) and uric acid (r = 0.36). Hypertensives had higher C-peptide levels than normotensives (1.04 +/- 0.04 versus 0.88 +/- 0.04 nmol/ml, respectively (mean +/- S.E.), P < 0.05) and this statistically significant difference remained after adjustment for age and known duration of diabetes. In well-controlled NIDDM patients not receiving exogenous insulin, both C-peptide levels and the C-peptide/bloodsugar ratio have statistically significant relationships with clinical/biochemical variables presenting a well-known association with insulin resistance.

[Standardization of the Alzheimer's Disease Assessment Scale in a Spanish population]

We describe a Spanish adaptation and standardization of the Alzheimer's Disease Assessment Scale (ADAS) carried out as part of a prospective, coordinated study performed simultaneously in two Spanish health centers. Three diagnostic groups were defined: 21 healthy volunteers (normal group); 22 patients with cognitive deterioration but no dementia (CDND group); and 20 patients with Alzheimer type dementia (ATD group). The subjects were examined at the start of the study and after 3 and 6 months. The mean cognitive ADAS scores were significantly different in the 3 groups (F = 67.2, p = 0.0001), as follows: normal group, 7.6 +/- 2.1; CDND group, 12.4 +/- 4.5; and ATD group, 21.0 +/- 4.7. Likewise, the ADAS proved sensitive to the course of deterioration in the ATD group, while the other groups' scores improved. We conclude that the ADAS, and in particular the cognitive subscale, is useful for evaluating ATD patients, especially in the early phases of deterioration. It discriminates between ATD and CDND patients well.

[Isolated vasculitis of the peripheral nervous system]

We present a patient with a subacute asymmetrical sensorimotor polyneuropathy. The pathological features were predominantly loss of nerve fibers, axonal degeneration and healed vasculitis. The epineural vessels were involved, while endoneurial capillaires were preserved. Muscle biopsy revealed neurogenic features with normal blood vessels. After three years, motor and sensory function was almost normal, without any specific treatment. No abnormal findings suggesting collagen diseases or other underlying immunological disorders were obtained by various laboratory tests. In conclusion, the present case strongly suggests that the vasculitis was confined to the peripheral nerves.

[Miller-Fisher syndrome associated with toxoplasmosis]

We report on an immunocompetent patient who developed acquired toxoplasmosis and Miller-Fisher syndrome with central and peripheral neural involvement. We suggest the possible relationship between acquired toxoplasmosis and Miller-Fisher syndrome, even though we cannot exclude a mere coincidence. To our knowledge such an association has not been reported.

Lack of association of lipoprotein (a) with coronary heart disease in Spaniard type 2 diabetic patients

We tried to elucidate the possible relationship between lipoprotein (a) levels and coronary heart disease by assessing the presence of lipoprotein (a) covariates in NIDDM. We selected 41 type 2 diabetic patients with coronary heart disease and 82 type 2 diabetic patients free from cardiovascular disease. They were adjusted for age, sex and duration of diabetes. Routine chemical analysis was carried out using standard procedures, HbA1c by HPLC and lipoprotein (a) and urinary albumin excretion rate by immunonephelometry. No difference has been found in lipoprotein (a) levels between both groups of patients (18 [144.25] mg/dl in cases vs. 23 [197.25] mg/dl in controls (median [range]), Mann Whitney U-test, P > 0.1). No association has been found between coronary heart disease and lipoprotein (a) levels greater than 30 mg/dl (Pearson's chi 2, P > 0.1). Significant and independent linear relationships have been found between the square root of lipoprotein (a) levels, serum creatinine and total cholesterol (multiple r2: 0.15, P < 0.001). Patients treated with insulin had greater square root of lipoprotein (a) levels, even after adjusting for serum creatinine and total cholesterol (5.87 +/- 0.35 vs. 4.76 +/- 0.36 (mean +/- S.E.), ANCOVA, P < 0.05). These data do not show an association between symptomatic coronary heart disease and lipoprotein (a) in NIDDM. Significant and independent relationships have been found between this variable and serum creatinine, total cholesterol and insulin therapy.

Radiation myelopathy in over-irradiated patients: MR imaging findings

The objective of this work is to report the MRI findings in patients with radiation myelopathy due to accidental local over-irradiation syndrome. Eight patients (seven males and one female) were suffering from over-irradiation syndrome as a result of treatments from a malfunctioning linear electron accelerator. The mean accidental estimated dose was 136 Gy delivered to the "open-neck" (seven cases) and to the thoracic wall (one case), during a mean of 5.4 sessions (range 1-9 sessions). Paresthesia and weakness in the upper extremities were the earliest symptoms (87.5 %), with evolution to paralysis in all patients. No patient is alive (mean survival time 64 days). In all cases MRI was negative for neurologic lesions in the acute phase ( < 90 days from irradiation; Radiation Therapy Oncology Group scoring system). Late signs of radiation myelitis manifested as high-intensity signals on T2-weighted images in three patients, and as Gd-DTPA enhancement of T1-weighted images in one case. Autopsies performed on four patients who died in acute phase showed morphologic alterations in white matter: edema in 75 %, and necrosis and glial reaction as well as obliterative vasculitis in all cases. In cases of over-irradiation, MRI may be normal in acute phase even if the patients have severe neurologic deficit, as positive MRI findings appear only in delayed radiation myelitis.

[Reading-induced epilepsy: three new cases]

INTRODUCTION

Primary epilepsy of reading is a rare syndrome in which patients present with mandibular myoclonia when reading texts. Seizures are also frequently provoked by other stimuli. Occasionally they may be followed by generalized tonic-clonic seizures.

CLINICAL CASES

We present the clinical features and electroencephalographs of three patients with epilepsy of reading, one of them also had seizures when playing chess and after doing arithmetic and the third after reading music. Treatment with valproic acid and clonazepam completely controlled the seizures in all three patients. In two cases we saw epileptiform activity on EEG whilst they were reading, although the basal EEG was normal.

CONCLUSIONS

We believe that epilepsy of reading is under-diagnosed and emphasize the importance of careful questioning of epileptic patients as to factors which may precipitate the seizures. In view of the social problems which may arise, early recognition of the syndrome is important for the patient.

[Epileptic seizures during sleep]

Introduction. Epileptic crises presenting exclusively during sleep are rare and pose more problems of diagnosis than do crises of diurnal presentation.

PATIENTS

We present the clinical and electroencephalographic data of 20 patients with exclusively sleep-induced epileptic crises, evaluating not only the type of crises and the diagnosis of the particular syndrome, but also the response to treatment and prognosis. The patients studied were over 17 years old, had only nocturnal crises and were followed up for a period of three years. An EEG done during sleep and cerebral CT scan were available in all cases and a cranial MR was available in two cases. Diagnosis was made using clinical data and the sleep EEG.

RESULTS

The majority (40%) had temporal lobe epilepsy. In two patients (10%) occipital paroxysms were found. In all cases both the neurological examination and the mental state were normal. The sleep EEG was pathological in 75% of the cases. Only three of the twenty patients had changes on the CT scan. Monotherapeutic antiepileptic treatment completely controlled the crises in 15 patients.

CONCLUSIONS

We wish to emphasize the usefulness and importance of the sleep EEG in defining the syndrome affecting these patients, the diagnostic difficulties in sleep epilepsy, the good response to antiepileptic treatment and the high incidence of recurrence if antiepileptic treatment is no longer given. In view of all these factors we believe that sleep epilepsy may be considered to be a syndrome of epilepsy.

Subarachnoid-pleural fistula as a complication of the lateral-extracavitary approach to thoracic intraspinal neurinoma

STUDY DESIGN

This report describes an infrequent but major complication resulting from a lateral extracavitary approach to the spinal cord. The diagnosis was made via myelography-computed tomography.

OBJECTIVES

The authors emphasize the importance of a proper approach in diagnosing a subarachnoid-pleural fistula and treating this clinical condition correctly.

SUMMARY OF BACKGROUND DATA

Myelography-computed tomography was used to diagnose the subarachnoid-pleural fistula. It was necessary to re-open the thoracotomy to seal the dura mater because the pleuroperitoneal shunting was not effective.

METHODS

The patient presented with an intradural and extramedullary thoracic neurinoma located on the anterior part of the spinal canal that was causing anterior spinal cord compression. A lateral extracavitary approach was taken with a thoracotomy, with the tumor being completely removed. During the postoperative period, the patient had a persistent pleural effusion. The diagnosis of a cerebrospinal fluid fistula was made via myelography-computed tomography. Implantation of a pleuroperitoneal shunt was unsuccessful, and it was necessary to re-open the thoracotomy to seal the dura mater.

RESULTS

Myelography-computed tomography successfully helped diagnose the subarachnoid-pleural fistula and identify the precise anatomic location of the leakage. Pleuroperitoneal shunting was not effective in dealing with the pleural effusion.

CONCLUSIONS

This complication should be taken into account when this kind of surgical approach is performed. Myelography-computed tomography is the most reliable test for diagnosing this clinical condition and pinpointing the exact location of the leakage.

Interspecific reassortment of genomic segments in the evolution of cucumoviruses

Segmented genomes of RNA viruses are thought to evolve and be maintained in analogy to sexual recombination and reassortment in eukaryotic systems. If reassortment among genomes is an important event in cucumoviral evolution, then such events should be detectable among extant viruses. In this study, phylogenetic analyses of cucumoviruses were performed using aligned amino acid sequences. The results reveal different relationships among species when the three genomic segments are compared, suggesting that reassortment events have given rise to extant forms. In addition, we describe a cucumovirus isolate that is composed of genomic segments from two distinct viral species. These results indicate that reassortment events may provide a mechanism for speciation in cucumoviruses.

[Silent myocardial ischemia in patients with transient ischemic attacks]

Given evidence that ischemic heart disease is the most frequent cause of death in patients with cerebrovascular disease, we used ergometrics to screen 80 patients with TIA for silent myocardial ischemia (SMI) at the neurological unit of Hospital Clínico Universitario in Zaragoza, Spain. The patients were compared with a control group of 80 with no signs of heart disease. Neither the patients nor the controls had ever shown clinical signs of coronary ischemia and their baseline electrocardiograms were normal. Stress test results were positive in 25 (31%) of the TIA patients, and in 4 (5%) (p < 0.001) of the controls, showing that the prevalence of SMI is significantly higher in TIA patients than in the general population. Hiperlipidemia (75% testing positive versus 43% negative, p < 0.01) and diabetes (31% testing positive versus 13% negative, p < 0.01) were the risk factors statistically related with a positive stress test.

Characterization of Blue-Green Fluorescence in the Mesophyll of Sugar Beet (Beta vulgaris L.) Leaves Affected by Iron Deficiency

The mesophyll of sugar beet (Beta vulgaris L.) leaves emits red (chlorophyll a) fluorescence and blue-green fluorescence when excited with ultraviolet light. The intensity of blue-green fluorescence was increased in mesophylls affected by iron deficiency. This increase was large and progressive. It was concomitant with a decrease of photosynthetic pigments per unit of leaf area. Most of the increase in blue-green fluorescence can be explained by the decrease of the screening of ultraviolet light by chlorophylls and carotenoids. In addition, chlorophylls selectively reabsorb blue fluorescence, which leads to a change in the form of the fluorescence emission spectra. This effect induces an increase of the blue-to-green fluorescence ratio in control mesophylls that was concomitant with the decrease of chlorophyll per unit of leaf area. Iron deficiency induced a decrease of the blue-to-green fluorescence ratio that may be attributed to an accumulation of flavins fluorescing in the green. Time-resolved fluorescence measurements indicate that they are mostly riboflavin and/or flavin mononucleotide phosphate. Our data also indicate that the blue-green fluorescence emitted from the mesophyll contains fluorescence of nicotinamide nucleotides.

Vascular malformation of the cerebellopontine angle associated with "SUNCT" syndrome

A 70-year-old man complained of two distinct types of unilateral headache during the past fifteen years. When the illness began, the pain was intermittent and short-lasting. In successive years, the crises appeared in clusters and lasted weeks to months. At present, the pain occurs daily, and is located on the right side, from the forehead supraorbitally to the temporal region. Some attacks last 30 sec and are accompanied by tearing, conjunctival injection, rhinorrhea and a subjective need to micturate. Other headaches last 1/2-1 h and are occasionally accompanied by local ipsilateral dysautonomic symptoms. Attacks of pain are provoked by movements of the trunk and neck. A vascular malformation in the right cerebellopontine angle was demonstrated on cranial CT and MRI, and by angiography.