Tuberculous vertebral osteomyelitis in the new millennium: still a diagnostic and therapeutic challenge

In order to determine the clinical features and current prognosis of tuberculous vertebral osteomyelitis, the charts of all patients diagnosed with definite or probable tuberculous vertebral osteomyelitis from January 1983 to June 2002 ( n=78) were reviewed. The mean delay to diagnosis was 6.1 months. Sixty-five (83.3%) patients had inflammatory spinal pain, 35 (44.9%) had some neurological deficit, and only 27 (34.6%) had fever. Paravertebral, epidural, and psoas abscesses were detected in 73.1, 65.4, and 24.4% of the cases, respectively. Culture was positive in 48% of the percutaneous biopsies and in 61.7% of the open biopsies. After histological findings were included, the diagnostic yield of percutaneous biopsies was 68%. Fifty-five (70.5%) patients required surgical treatment at some stage of the disease. Although no deaths were directly attributable to tuberculous vertebral osteomyelitis and only 5.1% of patients relapsed, the mean overall hospital stay was 69.1+/-36.9 days, and 30 (38.5%) patients had severe functional sequelae. In conclusion, diagnosis of tuberculous vertebral osteomyelitis requires a high degree of suspicion. Percutaneous biopsy should be undertaken as soon as possible in any patient with compatible symptoms or radiological images in order to initiate suitable therapy.

Activation of electrocorticographic activity with remifentanil and alfentanil during neurosurgical excision of epileptogenic focus

BACKGROUND

Opioids are known to stimulate surface electroencephalographic activity in patients with temporal lobe epilepsy. The objective of the current study was to compare the electrocorticographic activation effects of the newer short-acting opioid remifentanil with those of alfentanil during epilepsy surgery under general anaesthesia.

METHODS

Thirteen patients undergoing temporal lobe epilepsy surgery under general anaesthesia received alfentanil 30 microg kg(-1) and remifentanil 1 microg kg(-1) as i.v. boluses in sequence. The design was a randomized double-blind cross-over study. After opening the dura, electrocorticogram (ECoG) electrode contact strips were placed over the temporal and supratemporal neocortex and depth electrodes were inserted in the amygdala and hippocampus. Alfentanil 30 microg kg(-1) or remifentanil 1 microg kg(-1) were administered randomly in a blinded fashion. The ECoG was recorded continuously before and after the injection of each drug. The interictal epileptiform activity (spikes and sharp waves) above baseline was analysed.

RESULTS

Both drugs increased epileptiform activity especially that recorded from depth electrodes in the temporal limbic structures. No epileptiform activity was recorded from the electrodes overlying the supratemporal neocortex before or after drug administration. The more potent activator was alfentanil, which caused an increase in activation from baseline of 99.8% compared with 67.4% for remifentanil. In addition, alfentanil activated the epileptiform activity in 3 patients in which remifentanil had no effect. There were no changes in heart rate after the opioid boluses. Both remifentanil and alfentanil caused significant reductions in blood pressure at 3 and 5 min after administration.

CONCLUSION

We conclude that at the doses used in this study, alfentanil is the better opioid for intraoperative activation of the ECoG in neurosurgical patients undergoing resection of a temporal lobe epileptic focus. This pharmacological activation of epileptiform activity assists in localizing and confirming the site of surgical excision. Neither alfentanil nor remifentanil activated epileptiform activity in non-epileptic brain tissue.

[The neurobiology of developmental dyslexia: a survey]

One of the most common disorders affecting the ability to read is developmental dyslexia, which, unlike the alexia related to a loss of the capacity to read associated with brain damage, refers to a specific disorder in the acquisition of reading skills and becomes apparent in reiterated persistent difficulties in learning to read. A number of studies have attempted to detect structural and functional abnormalities that might be the origin of problems in learning to read. The use of functional neuroimaging techniques such as positron emission tomography (PET), spectroscopic magnetic resonance imaging (SMRI) and functional magnetic resonance imaging (fMRI) enables us to measure changes in the metabolic activity associated with alterations in the neuronal networks involved in the reading process. In this review, different studies are analysed in an attempt to identify alterations in the cortico subcortical regions which could be the origin of the developmental dyslexia. Results show that in dyslexics there is a temporoparietooccipital disconnection, and a disconnection with the left frontal cortex as regards the demands for fast auditory processing, as well as abnormalities in the connections between the temporoparietal cortex and the cerebellum with other regions of the brain. Such findings suggest that the altered areas of the brain do not only show a characteristic pattern of hypoactivation, but also that these alterations could be the cause of this malady. We highlight the importance of these findings in the diagnosis and rehabilitation of this population.

Common herbs, essential oils, and monoterpenes potently modulate bone metabolism

During our survey of herbs looking for activity on bone metabolism, we found that the dried leaves of sage strongly inhibit bone resorption. Therefore, we investigated several common herbs rich in essential oils (sage, rosemary, and thyme) and essential oils extracted from these herbs and other plants (oils of sage, rosemary, juniper, pine, dwarf pine, turpentine, and eucalyptus) as well as their monoterpene components (thujone, eucalyptol, camphor, borneol, thymol, alpha-pinene, beta-pinene, bornylacetate as well as menthol) and found that they inhibit bone resorption when added to the food of rats. Pine oil, used as a representative essential oil, protects an osteoporosis model, the aged ovariectomized rat, from bone loss. The monoterpenes borneol, thymol, and camphor are directly inhibitory in the osteoclast resorption pit assay. Nonpolar monoterpenes may require metabolism to be active in vitro, for example, cis-verbenol, a metabolite of alpha-pinene occurring in human urine, inhibits osteoclast activity in contrast to the parent compound. Within 30 min borneol inhibits the formation of actin rings, a characteristic of resorbing osteoclasts indicating cell polarization. Both the in vitro and the in vivo effects of borneol are reversible. Our study demonstrates for the first time that essential oils and monoterpenes are efficient inhibitors of bone resorption in the rat.

Non-pigmenting cutaneous-mucosal fixed drug eruption due to piroxicam

BACKGROUND

Piroxicam is a widely used anti-inflammatory drug. Most adverse reactions affect gastrointestinal system, liver and skin. Fixed drug eruption although very unusual, has also been described, but with cutaneous involvement exclusively. We present the case of a 49-year-old man who suffered three episodes of fixed drug eruption with cutaneous-mucosal involvement, even simulating an autoimmune disease, whenever he was treated with oral piroxicam.

METHODS AND RESULTS

He was patch tested on normal skin with the GEIDC standard series and an NSAIDs series. He was patch tested on normal skin and on fixed eruption with piroxicam, meloxicam and tenoxicam (all of them 1 % pet). Oral challenge test was not performed due to the severity and reproducibility in previous reactions. Results showed a positive patch test to piroxicam (1 % pet) on fixed eruption, with negative results to the rest.

CONCLUSIONS

Adverse drug reactions may present a wide variability of clinical symptoms. In these situations an accurate clinical history is necessary. To our knowledge this is the 1st report of non-pigmenting fixed drug eruption with cutaneous-mucosal involvement due to piroxicam. Cross-reactivity between oxicams could not be demonstrated by patch test on fixed eruption.

In vitro comparison of root-canal measurements with conventional and digital radiology

AIM

The present study compared the efficacy of digital and conventional radiology for root-canal length measurement.

METHODOLOGY

Seventy extracted teeth with pre-served roots were used. Root-canal length measurements were completed with K-Flexofiles (numbers 08, 10 and 15) with conventional and digital radiography using two systems (radiovisiography and photostimulate storage phosphor). All films and sensors were exposed at projections of 0 degrees and 20 degrees to the mesial. The images obtained were evaluated with and without magnification, and analysed using the Cohen's kappa test. The accuracy of the three systems to determine the root-canal length were evaluated by measuring the distance from the tip of the file to the apex.

RESULTS

Most of the values corresponding with the apex occurred with conventional radiology. The digital systems yielded negative values that improved with a size 15 file. The agreement between the two digital systems was the best with size 15 file using 0 degrees projection (66.7%).

CONCLUSIONS

Conventional radiology remains the technique of choice in determining the root-canal length; the digital techniques yielded good results for size 15 file.

Effect of several germination conditions on total P, phytate P, phytase, and acid phosphatase activities and inositol phosphate esters in rye and barley

Two assays were conducted to study the evolution of rye and barley phosphatases (phytase and acid phosphatase) and the degradation of its substrates (inositol phosphate esters) during seed germination. In this manner we could obtain a low-phytate, endogenous phosphatase rich ingredient to be used in animal nutrition. In the first assay, the seeds were soaked for 1 and 14 h and germinated for 3 and 5 days with and without the addition of gibberellic acid (GA3). In the second assay, the seeds were soaked for 1 h and germinated for 1, 3, and 5 days with GA3. Phytase (up to 5739 and 3151 U x kg(-1)) and acid phosphatase (up to 18288 and 3151 U x g(-1)) activities, and IP6 (6.09 and 6.01 mg x g(-1)), IP5 (0.48 and 0.48 mg x g(-1)), and IP4 (0.13 and 0.06 mg x g(-1)) were detected in ungerminated rye and barley, respectively. The germination process caused a significant increase of Phy and AcPh activities in rye (up to 112 and 213%) and barley (up to 212 and 634%) and a reduction in the phytate phosphorus content (up to 84 and 58%, respectively). Phytate phosphorus content was affected only by soaking time in the case of rye. Finally, during the course of germination, IP6 and IP5 were rapidly degraded in rye (88 and 79%) and barley (67 and 52%), and IP4 was only a short-living intermediate, which was increased during hydrolysis and degraded to IP3. In conclusion, a marked increase of Phy and AcPh activities in rye and barley with a concomitant decrease in phytate phosphorus content and an increase in the content of lower inositol phosphates were observed during the rye and barley germination.

Biweekly gemcitabine, doxorubicin, and paclitaxel as first-line treatment in metastatic breast cancer. Final results from a phase II trial

In a single-center, open, phase II trial, we assessed the toxicity and activity of a triple combination therapy--doxorubicin at 30 mg/m2 (day 1), paclitaxel (Taxol) at 135 mg/m2 (day 2), and gemcitabine (Gemzar) at 2,500 mg/m2 (day 2 after paclitaxel)--administered biweekly in a 28-day cycle for six cycles. This was given as first-line treatment in 41 patients with metastatic breast cancer. Granulocyte colony-stimulating factor was used in 27 patients to permit maintenance of dose density. Hematologic toxicity was moderate. Nonhematologic adverse events were generally mild. The objective response rate was 82.9% (34/41) with 18 patients (43.9%) achieving complete response and 16 (38%) achieving partial response; progressive disease was observed in 4 patients (9.8%). Responses were observed at all metastatic sites, including complete responses in lung, liver, bone, and soft tissue. Median duration of response was 14.1 months and median time to progression was 13.9 months. Median survival was 26.2 months. The biweekly combination of gemcitabine, doxorubicin, and paclitaxel is safe and highly active as first-line treatment in metastatic breast cancer.

Some vegetables (commonly consumed by humans) efficiently modulate bone metabolism

We have hypothesized that some vegetables which are part of the regular human diet may contain modulators of bone metabolism. To mimic a typical Western diet with large proportions of refined components, rats were pair-fed a semi-purified diet to which, in the treated animals, the dried material under investigation was added. Effects are expressed as % of untreated control. Bone parameters in rats were assessed in the proximal tibia by pQCT. Bone resorption (BR) was assessed by the urinary excretion of [3H]-tetracycline from prelabeled rats. Daily administration of 1 g of onion during 4 weeks increased total bone mineral content by 17.4% (p<0.05), trabecular bone mineral density by 13.6% (p<0.05). One g of onion/day administered to male rats blunted BR by 23-/+5% (p<0.05). Daily administration of onion to ovariectomized rats inhibited BR in a dose-dependent manner. At the highest dose (1.5 g of onion) BR was inhibited by 26-/+4% (p<0.01) as compared to 24-/+3% (p<0.001) for estradiol (27microg/kg/day). An additional 13 vegetables displayed significant effects on BR at the dose of 1g/day. Interestingly, 1g/day of soy did not inhibit BR in this model. Also, skimmed milk, meat and egg (all 1 g/day) were ineffective. Thus, common vegetables consumed by humans potently modulate bone metabolism in the rat. This opens the possibility to develop the basis for a low-cost, safe and effective nutritional approach to osteoporosis.

Detection of hepatitis G virus (HGV) RNA and antibodies to the HGV envelope protein E2 in a cohort of hemodialysis patients

An analysis of the evolution of hepatitis G virus (HGV) infection markers was performed for a cohort of 58 hemodialyzed patients. During follow-up (4.88 +/- 0.42 years), a group of these patients cleared their antibodies against the envelope protein E2 with (4 of 29 cases; 13.8%) or without (9 of 29 cases; 31%) the reappearance of viremia. This finding implies a temporally limited protection in patients previously infected with HGV.

Phase II trial of gemcitabine/doxorubicin/paclitaxel administered every other week in patients with metastatic breast cancer

The present trial was designed to determine the efficacy of the combination of gemcitabine/doxorubicin/paclitaxel (GAT) delivered every other week as first-line therapy in patients with metastatic breast cancer. From February 1998 to September 1999, 41 patients were included in this trial. Doses delivered were doxorubicin 30 mg/m2 on day 1 and paclitaxel 135 mg/m2 plus gemcitabine 2500 mg/m2 both given on day 2, every 14 days. Doses were selected from a previous phase I trial conducted at our institution. Eligibility criteria for the phase II trial included histologically confirmed metastatic breast cancer with bidimensionally measurable lesions; no prior therapy for metastatic disease; adjuvant or neoadjuvant chemotherapy was allowed if given more than 1 year before and cumulative doses of doxorubicin or epirubicin were less than 200 mg/m2 or 360 mg/m2, respectively; Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less; and adequate hematological, hepatic, and renal function. Prophylactic use of granulocyte colony-simulating factor (G-CSF) was allowed if patients were not fully recovered (absolute neutrophil count greater than 1500/microL) from chemotherapy administration before the next dose. Left ventricular ejection fraction was determined initially, at the end of the study, and every 6 months thereafter. The patients' median age was 55 years (range, 33-68 years), and their median ECOG performance status was 0 (range, 0-1). Twenty-eight patients had received adjuvant therapy, 17 with epirubicin (none with doxorubicin). Metastases were present in the bone (19 patients), lung (19 patients), liver (11 patients), and soft tissues (18 patients). Twenty patients had one metastatic site and 21 had two or more sites. Efficacy was assessed on an intent-to-treat basis. A total of 216 cycles of GAT were given. Twenty-two percent of the courses were delayed or given at reduced doses mostly due to neutropenia or thrombocytopenia. G-CSF was required in 58% of the cycles. Grade 3/4 neutropenia was the main toxicity and appeared in 17 patients, one of whom had an episode of febrile neutropenia. Nonhematological toxicities consisted mainly of neurotoxicity and myalgias. A drop of 10%-20% in the left ventricular ejection fraction was detected in two patients and another patient had a decrease greater than 20%, although none developed symptoms of heart failure. Overall response rate was 80.4% (95% confidence interval: 68.3-92.5), with 15 patients (36.6%) achieving a complete response. Median survival time was 27 months and median time to progression was 15 months. The GAT combination is feasible and very active in patients with metastatic breast cancer, with an encouraging response rate including a high rate of complete responses. No congestive heart failure was documented and other toxicities were mild, with the exception of neutropenia.

Phytase and acid phosphatase activities in plant feedstuffs

A total of 183 samples representing 24 feedstuffs were analyzed for total phosphorus, phytate phosphorus content, phytase (Phy), and acid phosphatase (AcPh) activities with the objective to predict the capacity to hydrolyze phytic acid and to contribute to formulating environmentally adequate diets for monogastric animals. Of the cereals and cereal byproducts analyzed, only rye (5147 U kg(-)(1); 21 955 U g(-)(1)), wheat (1637 U kg(-)(1); 10 252 U g(-)(1)), rye bran (7339 U kg(-)(1); 56 722 U g(-)(1)), and wheat bran (4624 U kg(-)(1); 14 106 U g(-)(1)) were rich in Phy and AcPh activities. Legume seeds and oilseeds contained negligible Phy activity and a moderate amount of AcPh activity, except for kidney bean (33 433 U g(-)(1)) and full-fat linseed meal (13 263 U g(-)(1)). On the other hand, a significant linear regression between phytate phosphorus (y) and total phosphorus (x) was observed in cereal byproducts (R(2) = 0. 95; y = 0.8458x - 0.0367; P < 0.001) and oil seeds (R(2) = 0.95; y = 0.945x - 0.20; P < 0.001). Phy and AcPh were positively correlated with respect to phytate phosphorus in cereals, cereal byproducts, and other byproducts and negatively correlated in legume seeds and oilseeds. Except for cereals, the highest correlation between enzyme activities and phytate phosphorus was found for phytase. It is not possible to predict Phy and AcPh activities from phytate phosphorus content by linear and quadratic regressions. Finally, only highly significant and positive correlation was found between Phy and AcPh activities for cereals, cereal byproducts, and oilseeds.

Immediate motor effects of stimulation through electrodes implanted in the human globus pallidus

The immediate motor effects of stimulation through electrodes chronically implanted in the globus pallidus internus (GPI) were studied in 9 subjects with Parkinson's disease. Single stimuli (at >>0.4 Hz) produced short latency facilitation of voluntarily activated contralateral muscles in all subjects. The latency and distribution of the facilitation, its probably monosynaptic nature, and the short chronaxie and refractory period of the activated neural elements suggest that the facilitation results from the direct excitation of the fast conducting corticospinal pathway. The facilitation of motoneurons followed high frequency (e.g. 200 Hz) stimulation without decrement and occurred at stimulus intensities well below those required to produce a visible muscle contraction. We conclude that, while there may be other effects, GPI stimulation through electrodes may activate the corticospinal tract, even when the stimuli are below the threshold for a visible muscle contraction, and that continuous stimulation may do so continuously. This may be an unwanted side effect, but possible therapeutic actions are considered. The reproducible short latency facilitation enabled us to estimate current spread from the quadripolar electrodes used for deep brain stimulation. When the current is sufficient to excite large myelinated fibers near one of the quadripolar electrodes, an additional 1-mA current will activate similar fibers at an additional distance of 1.8 mm with bipolar stimulation and at a distance of 5.7 mm with monopolar stimulation.

[Surgical treatment of dystonia]

INTRODUCTION AND DEVELOPMENT

Dystonia is a neurological syndrome which is often progressive and disabling. The pathophysiological basis is only partly understood. Medical treatment often fails. Peripheral surgical techniques can alleviate the symptoms of many patients with diverse forms of focal dystonia. In patients with generalized dystonia, central surgical techniques are preferable. Thalamotomy is the best known technique, although the target is not fully defined. Experience with surgery of the pallidum and subthalamus is very limited, but results are promising.

CONCLUSIONS

More studies are necessary to discover the precise potential benefit of these techniques and define the ideal candidates. It is important that such studies should be done using rigorous methodology and be similar for all groups working on this.

Enteroviruses in Spain: virological and epidemiological studies over 10 years (1988-97)

A total of 15,662 clinical samples were analysed for enterovirus (EV) isolation in cell cultures during a 10-year period (1988-97). Furthermore, 210 isolates of EV obtained in primary laboratories within Spain from patients with meningitis were characterized. The total number of EV typed was 758, including 727 non-polio EV and 31 Sabin-like (SL) polioviruses. Twenty-eight EV serotypes were represented. Echoviruses comprised 90% (653/727) of fully typed non-polio EV. The four most prevalent serotypes were echovirus 30, echovirus 9, echovirus 6 and echovirus 4. Echovirus 30 was the main serotype associated with meningitis. Echovirus 9 was the aetiological agent in 20 outbreaks of meningitis while the occurrence of echovirus 6 was localized in 1 year (1997). Coxsackieviruses A and B occurred in 3 and 7% of the non-polio EV respectively. Coxsackievirus B5 presented the relative greater abundance. This paper examines the epidemiology of EV in Spain to serotype level over a 10-year period with special attention to non-polio EV associated with meningitis.

[PREGNANCY AND HEPATITIS CIRRHOSIS]

We report a case of a pregnant woman of 33 years old, suffering from hepatic cirrhosis by Hepatitis B with splenomegaly and portal hypertension, the 40 weeks pregnancy ended succesfully with a newborn weighting 2,900 g born by vaginal delivery.

[CLINICAL AND IMMUNOLOGICL PROFILE IN 22 PATIENTS WITH PRIMARY BILIARY CIRRHOSIS]

The primary biliary cirrhosis (PBC) is a no frequent entity in our country. Its diagnosis is based on clinical features, cholestasic pattern in liver function tests and the presence of antimitochondrial antibody in 90% of cases and other auto-antibodies in the serum, all this information is supported by characteristic hepatic histopathologic data. Also some clinical variants have been described that has suggested different denominations such as Overlap Syndrome, associated to autoimmune hepatitis and autoimmune colangitis, known by its persistent negativity of the antimitochondrials antibodies.The present study reports the clinical, biochemical and immunological findings of 22 patients with histopathologic diagnosis of PBC observed between 1994 and 1999, in Arzobispo Loayza Hospital and private offices, in Lima, Per .Results shown a cholestatic pattern in 100% of patients, jaundice in 95%, pruritus in 86%, hyperpigmentation of skin in 40.9%, hepatomegaly in 36.9% splenomegaly in 37.3% and xantelasma in 36%; alkaline phospatase was increased between 5 and 30 times the normal values in all patients, oxalacetic and piruvic transaminases were increased more than twice the normal values in 95% and 90%, respectively and hypercholesterolemia in 89% of patients; the antimitochondrial antibodies were positive in 64%, antinuclear antibodies in 32% and anti smooth muscle in 18%; 7 patients present associated autoimmune diseases, 4 with sicca syndrome, 2 with vitilige and 1 with hemolitic anemia. Three patients were classified as primary biliary cirrhosis, associated to autoimmune hepatitis; 4 patients died during the follow up and six patients were treated with ursodeoxicholic acid for more than six months.We can conclude that the profile found is a cholestasic pattern with jaundice in the majority of patients, low positivity of mitochondrial antibodies; there was no difference between AMA positive and negative patients, and in the third part of patients it was observed an associated immune disease and in three cases there was evidence of association with autoimmune hepatitis (Overlap Syndrome). Finally, the treatment with ursodeoxicolic acid improves some biochemical parameters, but apparently, they do not survival improve.

Type III intermittency in human partial epilepsy

A rigorous characterization of the dynamic regimes underlying human seizures is needed to understand, and possibly control, the transition to seizure. Intra- or extracranial brain electrical activity was recorded in five patients with partial epilepsy, and the interictal and ictal activity analysed to determine the dynamics of seizures. We constructed first-return one-dimensional maps by fitting the scatter plots of interpeak intervals. The features of the mapping indicated that type III intermittency is the dynamic characteristic of the ictal events. This was confirmed using histograms of the durations of the regular phases during seizures. The intermittent regime explains the abrupt transitions observed during ictal events in terms of transient stabilization of the unstable steady state.

Syringomyelic dystonia and athetosis

Two patients with movement disorders associated with syringomyelia are described, one of whom developed unusual torticollis, and the other had choreoathetoid-dystonic movements of the hand and arm. In each case, the movements resolved with decompression of the syrinx. The literature is reviewed and possible mechanisms explored.

Cisplatin, radiation, and amifostine in carcinoma of the uterine cervix

A pilot, open, comparative study was performed on patients with locally advanced cervical cancer to investigate the efficacy and safety of amifostine. Twenty patients with a histologic diagnosis of squamous cervical cancer were treated with radiotherapy and randomized in two groups. Group A received cisplatin at 20 mg/m2 for five days in two cycles during intracavitary radiotherapy and 100 mg/m2 x 2 cycles during external radiotherapy, and amifostine 825 mg/m2 15 min before the cisplatin infusion. Patients in group B received cisplatin in the same doses without amifostine. All patients had complete responses during a median follow-up of 20 months. Grade three neutropenia was present in two patients in group A and in four of the control group, P = 0.31; grade 2 neurologic toxicity was seen in four patients in group B and in one of the patients in group A, P = 0.15. One patient needed temporary interruption of amifostine due to hypotension. Eight of 10 patients in group A developed hypocalcemia during the treatment with amifostine. Our findings indicate that amifostine was well tolerated. In this series a mild neurologic and hematologic protection was found in patients that received amifostine, although this was not statistically significant. No differences in disease-free survival response and overall survival was seen between the two groups.

Spontaneous remission of primary central nervous system lymphoma: report of 3 cases and discussion of pathophysiology

Primary central nervous system lymphoma (PCNSL) is a relatively uncommon disease in which spontaneous remission is exceedingly rare. We are reporting three cases of primary CNS lymphoma with spontaneous regression in two to eight weeks, from the time of the initial diagnosis. The remission lasted for four years in the first case, two years in the second, and one year in the third case. Tissue diagnosis was made in the first two cases after relapse, and in the third case a biopsy was done at the initial presentation. The literature and the possible pathophysiological mechanisms of this interesting phenomenon are discussed.

Transient epileptic foci associated with intracranial hemorrhage in patients with subdural and epidural electrode placement

We report two cases of transient epileptic foci in humans associated with placement of intracranial electrodes. The abnormalities consisted of restricted areas of active, almost continuous, rhythmic spiking, intermittently evolving into electrographic seizure activity, which resolved spontaneously within 3-4 days. The first occurred after placement of a subdural electrode grid and the second following insertion of epidural peg electrodes. Neuroimaging demonstrated a small subdural hematoma overlying the grid and a focal intraparenchymal hemorrhage underlying the affected epidural electrodes. The insertion of intracranial electrodes may be complicated by the induction of transient epileptic foci unrelated to a patient's typical epileptic generator.

Role of electrocorticography at surgery for lesion-related frontal lobe epilepsy

BACKGROUND

The prognostic significance of epileptiform activity (EA) recorded intraoperatively at electrocorticography (ECOG) in patients with lesion-related frontal lobe epilepsy (FLE) is unknown.

METHODS

The results of ECOG performed in 22 patients with intractable FLE and a circumscribed frontal lobe structural lesion were compared with postoperative seizure control. Three patients underwent re-operation for a total of 25 cases, 23/25 with post-resection ECOG. Lesions were neoplasms (12), hamartomas (6) and arteriovenous malformations (4).

RESULTS

Outcomes were 15/25 Class I, 5/25 Class III and 5/25 Class IV (Engel classification). Class I outcome was associated with pre-excision EA recorded from < or = 2 gyri (p < 0.05) and absence of EA, or EA limited to the resection border, at post-excision ECOG (p < 0.01). Complete lesion excision was highly correlated with Class I outcome (p < 0.001). The most significant correlations were seen when ECOG and lesionectomy variables were considered together: all 12 cases with complete lesionectomy and absent post-excision EA distant to the resection border had Class I outcome (p < 0.00015) and all 13 cases with complete lesionectomy and pre-excision EA recorded from < or = 2 gyri had Class I outcome (p < 0.00005).

CONCLUSIONS

Postoperative seizure control in lesion-related FLE is assured in the setting of complete lesion resection with pre-excision EA recorded from < or 2 gyri and no post-excision EA distant to the resection border; complete lesion excision is of paramount importance.

Regulation of expression of galanin and galanin receptors in dorsal root ganglia and spinal cord after axotomy and inflammation

Galanin can normally be detected only in a few dorsal root ganglion (DRG) neurons, but it is dramatically upregulated after peripheral nerve injury in both rat and monkey. Galanin is stored in large dense core vesicles, which after axotomy are often found close to the membrane of afferent nerve endings in the dorsal horn. In the monkey there is an increase in galanin in many nerve terminals in the superficial dorsal horn after axotomy, but such an increase is more difficult to detect in the rat. Galanin is also present in local dorsal horn neurons, where it is upregulated by peripheral inflammation. Both galanin-R1 and galanin-R2 receptor mRNAs are expressed in rat DRGs, mainly in, respectively, large and small DRG neurons. Galanin-R1 receptor mRNA is downregulated in DRG neurons after axotomy, and a small decrease in galanin-R2 receptor mRNA levels can also be seen. After peripheral tissue inflammation galanin-R1 receptor mRNA levels decrease and galanin-R2 receptor mRNA levels increase. The present results show that galanin and galanin receptors are present in sensory and local dorsal horn neurons and are regulated by nerve injury and inflammation. Galanin may therefore be involved in processing of pain information, primarily exerting analgesic effects. Whereas local dorsal horn neurons represent a defense system against inflammatory pain, we have proposed that a second defense system, against neuropathic pain, is intrinsic to DRG neurons.

Pallidal stimulation in Parkinson's disease patients with a prior unilateral pallidotomy

OBJECTIVE

To evaluate, in a double-blind fashion, the efficacy of deep brain stimulation of the internal segment of the globus pallidus (GPi) contralateral to a previous unilateral medial pallidotomy (MP).

METHODS

This pilot study involved 4 patients with a previous MP and one previously unoperated patient unable to tolerate any antiparkinsonian drugs. One of the patients with a prior unilateral MP had two electrodes implanted in the contralateral side, one in GPi and one in Vim thalamus. Detailed neurologic assessments were performed after overnight drug withdrawal and in the drug "on" state at baseline, 1 week and 3 months (in all), and 9 and 12 months (one) with patients and evaluators blinded to the status of stimulation.

RESULTS

GPi stimulation resulted in improvements in "off-period" contralateral bradykinesia, rigidity and tremor in all patients. Dyskinesias and freezing episodes were ameliorated in one patient each but dyskinesias were transiently induced in another. The patient with GPi + Vim electrodes had complete resolution of contralateral tremor with thalamic stimulation but less benefit from acute GPi stimulation. One patient experienced a single seizure one week post-op and no other surgical complications were observed.

CONCLUSIONS

Deep brain stimulation can be applied safely and effectively in patients who have already had a pallidotomy on the contralateral side. The effect of stimulation at different sites on different symptom profiles and levodopa-induced dyskinesias requires further evaluation.

Incidence of silent hemorrhage and delayed deterioration after stereotactic brain biopsy

OBJECT

Many neurosurgeons routinely obtain computerized tomography (CT) scans to rule out hemorrhage in patients after stereotactic procedures. In the present prospective study, the authors investigated the rate of silent hemorrhage and delayed deterioration after stereotactic biopsy sampling and the role of postbiopsy CT scanning.

METHODS

A subset of patients (the last 102 of approximately 800 patients) who underwent stereotactic brain biopsies at the Toronto Hospital prospectively underwent routine postoperative CT scanning within hours of the biopsy procedure. Their medical charts and CT scans were then reviewed. A postoperative CT scan was obtained in 102 patients (aged 17-87 years) who underwent stereotactic biopsy between June 1994 and September 1996. Sixty-one patients (59.8%) exhibited hemorrhages, mostly intracerebral (54.9%), on the immediate postoperative scan. Only six of these patients were clinically suspected to have suffered a hemorrhage based on immediate postoperative neurological deficit: in the remaining 55 (53.9%) of 102 patients, the hemorrhage was clinically silent and unsuspected. Among the clinically silent intracerebral hemorrhages, 22 measured less than 5 mm. 20 between 5 and 10 mm, five between 10 and 30 mm, and four between 30 and 40 mm. Of the 55 patients with clinically silent hemorrhages, only three demonstrated a delayed neurological deficit (one case of seizure and two cases of progressive loss of consciousness) and these all occurred within the first 2 postoperative days. Of the neurologically well patients in whom no hemorrhage was demonstrated on initial postoperative CT scan, none experienced delayed deterioration.

CONCLUSIONS

Clinically silent hemorrhage after stereotactic biopsy is very common. However, the authors did not find that knowledge of its existence ultimately affected individual patient management or outcome. The authors, therefore, suggest that the most important role of postoperative CT scanning is to screen for those neurologically well patients with no hemorrhage. These patients could safely be discharged on the same day they underwent biopsy.

[Antibodies against the West Nile virus and other arthropod-transmitted viruses in the Ebro Delta region]

BACKGROUND

The West Nile Virus (WNV) is a Flavivirus which is transmitted to man by means of different species of mosquitoes and causes outbreaks and sporadic cases of illness in different regions of the Old World, including the Mediterranean Basin. Europe's wetlands which comprise a stopping-off point for birds migrating from Africa are high-risk areas as regards this infection, as well as other arthropod-borne virus infections.

METHODS

For the purpose of researching the prevalence of the WNV infection and other viruses transmitted similarly among the human population of the Ebro Delta, 1037 samples of serum taken in 10 towns in this area were analyzed to detect the presence of WNV antibodies and antibodies of another 12 arthropod-borne viruses (3 Alphaviruses, 8 Flaviviridae and 1 Bunyaviridae) by means of titration by inhibition of hemagglutination (HAI). In some cases, the presence of HAI-specific IgM was analyzed after breaking down the serum by centrifuging into sucrose gradients.

RESULTS

In all, a significant degree of reaction was found to some of the viruses tested in 130 cases (12.5%; 4.1% to Alphavirus; 8% to Flaviviridae and 0.4% to Bunyaviridae). The analysis of the antibody titers revealed significant percentages of samples showing high was titers to WNV and other types of antigens. The spread for the antibody prevalence was highly uneven, being focused mainly in 3 localities located in land on the Delta (Ampolla, San Jaime and Montells), where the prevalence of Flaviviridae antibodies totaled as high as 30%, with residual levels of WNV-related IgM having been found in some serum samples.

CONCLUSIONS

These results and those obtained previously in other parts of the Iberian Peninsula suggest that the WNV is moving throughout the human population in the areas where this risk is found to exist and periodically gives rise to epidemic outbreaks. Bearing in mind the high percentage of neurological complications found to exist in the most recent outbreaks of WNV infections recorded in the Mediterranean Basin (Bucharest, Algeria), it can be thought that the WNV plays some role in the factors contributing to viral meningitis and encephalitis which occur within the population of the areas at risk within Spain.

[ASSOCIATION OF DUODENAL DIVERTICULUM PRESENCE WITH CHOLEDOCHOLITHIASIS]

OBJECTIVES: The aim of this study was to investigate in aretrospective way the frequency of duodenal diverticulum and its association with choledocholithiasis. Methods:This study included 2728 consecutive patients who underwent ERCP during the period 1993-1997. Duodenal diverticulum was discovered in 122 cases (4.5%). In 22 patients cannulation was not achieved since it was not technically possible. Results: In 100 patients with successful cannulation, 54 cases with juxtapapillary diverticulum were encountered associated with choledocholithiasis. CONCLUSION: These data suggestthat duodenal diverticulum is associated with choledocholithiasis.

A 3-year follow-up of HCV-RNA viraemia in haemodialysis patients

BACKGROUND

Hepatitis C virus (HCV) infection in a population of haemodialysed patients was studied over a 3-year follow-up period in order to evaluate the changes in viral RNA, diversity of genotypes, and serological response to synthetic HCV peptides.

METHODS

Twenty-eight (32.9%) patients with anti-HCV antibodies from a total of 85 patients assigned to a haemodialysis unit were studied. The serological response to immunopeptides was evaluated by immunoblotting, viral RNA in serum was detected using the polymerase chain reaction (RT-PCR), and genotyping was carried out by hybridization with probes fixed to nitrocellulose paper.

RESULTS

Of the 28 haemodialysis patients who had anti-HCV antibodies, three (10.7%) were always RNA negative, six (21.4%) were always RNA positive, and 19 (67.8%) were variable RNA. There was an incomplete antibody response to non structural antigens in non-viraemic patients. Genotype was determined in 23 patients, and the other two could not be genotyped. The most common genotype was 1b (69.4%), followed by 1a (17.4%), and 2a, 3a, and 4a (each 4.4%).

CONCLUSIONS

Haemodialysis patients, when followed up for a long time, frequently show an intermittent HCV viraemia state, suggesting that HCV cannot be evaluated adequately by isolated RNA determinations.

[Laboratory diagnosis of subacute and acute encephalitis probably of viral origin: seven years of experience]

The results obtained in the laboratory diagnosis of 609 cases of acute or subacute encephalitis, studied during a period of time of even years, is briefly presented. Diagnostic methods included virus isolation from stools and cerebrospinal fluid (CSF); specific serology in serum; detection of intrathecal production of IgG antibody; and, in the last two years, detection of viral genome sequences in CSF by the polymerase chain reaction. Significant results were obtained in 196 cases (32.2%) and the alfa-herpesviruses were responsible for a major part of them (77.5%). Furthermore, 18 cases were likely to respond to dual infection by both herpes simplex and varicella-zoster viruses. Epstein-Barr virus and Human herpesvirus 6 were found in CSF from three immunocompetent patients. Besides the current vaccination program, measles virus is still responsible for an important part (22/196, 11.2%) of cases of viral encephalitis.

[HEMOBILIA: REPORT OF TWO CASES]

Hemobilia is defined as the hemorrhage within the biliary tree. Maybe, the abnormal communication between blood vessels and the billiary tree, is due to trauma, inflammatory disorders, infections, gallstones, tumors and coagulation disorders. Two cases, which diagnosis were made with retrograde endoscopic cholangio pancreatography, are reported here.

Multilevel anterior cervical corpectomy and fibular allograft fusion for cervical myelopathy

This study was conducted to determine the safety and efficacy of multilevel anterior cervical corpectomy and stabilization using fibular allograft in patients with cervical myelopathy. Thirty-six patients underwent this procedure for cervical myelopathy caused by spondylosis (20 patients), ossified posterior longitudinal ligament (four patients), trauma (one patient), or a combination of lesions (11 patients). The mean age (+/- standard deviation) of the patients was 58 +/- 10 years and 30 of the patients were men. The mean duration of symptoms before surgery was 30 +/- 6 months and 11 patients had undergone previous surgery. Prior to surgery, the mean Nurick grade of the myelopathy was 3.1 +/- 1.4. Seventeen patients also had cervicobrachial pain. Four vertebrae were removed in six patients, three in 19, and two in 11 patients. Instrumentation was used in 15 cases. The operative mortality rate was 3% (one patient) and two patients died 2 months postoperatively. Postoperative complications included early graft displacement requiring reoperation (three patients), transient dysphagia (two patients), cerebrospinal fluid leak treated by lumbar drainage (three patients), myocardial infarction (two patients), and late graft fracture (one patient). One patient developed transient worsening of myelopathy and three developed new, temporary radiculopathies. All patients achieved stable bone union and the mean Nurick grade at an average of 31 +/- 20 months (range 0-79 months) postoperatively was 2.4 +/- 1.6 (p < 0.05, t-test). Cervicobrachial pain improved in 10 (59%) of the 17 patients who had preoperative pain and myelopathy improved at least one grade in 17 patients (47%; p < 0.05). Twenty-six surviving patients (72%) were followed for more than 24 months and stable, osseous union occurred in 97%. These results show that extensive, multilevel anterior decompression and stabilization using fibular allograft can be achieved with a perioperative mortality and major morbidity rate of 22% and with significant improvement in pain and myelopathy.