Model of frequent, recurrent, and spontaneous seizures in the intact mouse hippocampus

This study presents a model of chronic, recurrent, spontaneous seizures in the intact isolated hippocampal preparation from mice aged P8-P25. Field activity from the CA1 pyramidal cell layer was recorded and recurrent, spontaneous seizure-like events (SLEs) were observed in the presence of low Mg2+ (0.25 mM) artificial cerebrospinal fluid (ACSF). Hippocampi also showed interictal epileptiform discharges (IEDs) of 0.9-4.2 Hz occurring between seizures. No age-specific differences were found in SLE occurrence (2 SLEs per 10 min, on average), duration, and corresponding frequencies. After long exposure to low Mg2+ ACSF (>3 h), SLEs were completely reversible within minutes with the application of normal (2 mM Mg2+) ACSF. The AMPA antagonist, CNQX, blocked all epileptiform activity, whereas the NMDA antagonist, APV, did not. The gamma-aminobutyric acid (GABA)A antagonist, bicuculline, attenuated and fragmented SLEs, implicating interneurons in SLE generation. The L-type Ca2+ blocker, nifedipine, enhanced epileptiform activity. Analysis of dual site recordings along the septotemporal hippocampus demonstrated that epileptiform activity began first in the temporal pole of the hippocampus, as illustrated by disconnection experiments. Once an SLE had been established, however, the septal hippocampus was sometimes seen to lead the epileptiform activity. The whole hippocampus with intact local circuitry, treated with low Mg2+, provides a realistic model of recurrent spontaneous seizures, which may be used, in normal and genetically modified mice, to study the dynamics of seizures and seizure evolution, as well as the mechanisms of action of anti-epileptic drugs and other therapeutic modalities.

Sporadic major hyperekplexia in neonates and infants: clinical manifestations and outcome

The aim of the present study is to report on the syndrome of sporadic major hyperekplexia during the neonatal period and early infancy, diagnosed in 39 patients at an average age of 3.3 months, the most severely affected during the first month of life. The patients mainly presented with marked irritability and recurrent startles in response to handling or even minute sounds, accompanied by rhythmic jerky movements and occasionally breath-holding episodes. Family history was negative for hyperekplexia, although eight parents reported jerky leg movements during sleep. The hallmark of hyperekplexia consisted of a hyper-alert gaze and an exaggerated startle with delayed habituation, also elicited by nose tapping and air blowing on the face accompanied by increasing rigidity. Nine severely affected infants, presenting with relentless startles, marked stiffness, violent rhythmic jerks, and breath-holding episodes were treated with oral low doses of clonazepam and completely recovered. Overall, the debilitating symptoms of hyperekplexia gradually resolved in all 39 infants, and their developmental assessment by 2 years of age was within the normal range. Therefore a prompt diagnosis of hyperekplexia during the neonatal period and early infancy, and then treatment if required with benzodiazepines to alleviate the debilitating symptoms, may prevent life-threatening events and enable better feeding and handling. Establishing the diagnosis of such a relatively benign disorder with a favorable developmental outcome may avoid unjustified extensive investigations or unnecessary treatment, suspecting an ominous progressive neurologic disorder.

Is diabetes an independent risk factor for mortality after myocardial infarction? The ARIC (Atherosclerosis Risk in Communities) Surveillance Study

We investigated the age-, gender- and race-specific 1-year case fatality rates of diabetic and non-diabetic individuals with a myocardial infarction. Data were obtained from the Atherosclerosis Risk in Communities (ARIC) Surveillance Study, which monitors both hospitalized myocardial infarction and coronary heart disease (CHD) deaths in residents aged 35-74 years in four communities in the USA. The study population comprised 3242 hospitalized myocardial infarctions (HMIs) in diabetic subjects and 9826 HMIs in non-diabetic individuals between 1987 and 1997. Age-adjusted and gender- and race-specific odds ratios (OR) for 1-year case fatality comparing diabetic to non-diabetic patients were 2.0 (95% CI, 1.6-2.4) for white men and 1.4 (95% CI, 1.1-1.8) for white women. Further adjustment for severity of HMI, history of previous MI, stroke and hypertension, and therapy variables showed significantly higher case fatality in white diabetic men than in non-diabetic white men (OR=1.5; 95% CI, 1.2-1.9), but no significant association in the other race-gender groups. The age-adjusted odds of out of hospital death was significantly higher among white diabetic men (OR=1.7; 95% CI, 1.2-2.3), white women (OR=2.3; 95% CI, 1.4-3.8), and African-American women (OR=2.9; 95% CI, 1.5-5.9) as compared to their non-diabetic counterparts. In conclusion, diabetes is an independent factor for mortality within one year following a myocardial infarction among white men, and following out-of hospital coronary death in white men and women and in African-American women. It is possible that these differences could be explained, at least in part, by a less than optimal medical management of the high cardiovascular risk profile of these patients after hospital discharge.

Central neurogenic hyperventilation in a conscious child associated with glioblastoma multiforme

Central neurogenic hyperventilation refers to progressive tachypnea leading to hypocarbia and respiratory alkalosis caused by cortical disorders, initially reported in comatose patients with mainly pontine infarction. Central neurogenic hyperventilation in conscious patients is even rarer, numbering around 30 reported cases including seven children, mainly associated with infiltrative gliomas and lymphomas of the brainstem and pons. We report the evolution of central neurogenic hyperventilation in a conscious child associated with an infiltrative glioblastoma multiforme diagnosed 1 year before admission. He presented with progressive tachypnea and dyspnea of 1 week duration. On examination he was fully alert and aware of his respiratory disorder. Respiratory rate was 56 breaths per minute using accessory respiratory muscles. Hyperventilation was unchanged during sleep. Arterial blood gases disclosed marked hypocarbia: Pco(2) of 8 mm Hg resulting in severe respiratory alkalosis at pH of 7.8. Central neurogenic hyperventilation was therefore suggested after exclusion of other respiratory or cardiac disorders. The exaggerated tachypnea persisted along with respiratory alkalosis. Over a period of 2 months his overall state markedly deteriorated; he lapsed into coma, and finally succumbed after involvement of medullary cardiovascular centers. Although extremely rare in the pediatric age group, central neurogenic hyperventilation should be suspected in any alert child presenting with unexplained increasing tachypnea and hypocarbia leading to respiratory alkalosis. The evolution of such a disorder may be an alarming sign of ensuing deterioration in patients with tumors of the brainstem and medulla before cardiovascular derangement.

Primary generalized epilepsy during infancy and early childhood

The present study delineates a benign generalized epileptic disorder during infancy and early childhood similar to the well-defined syndrome of primary generalized epilepsy in adolescence. The inclusion criteria for the study required infants under the age of 4 years mainly presenting with generalized nonfebrile seizures, requiring corroboration with generalized epileptic discharges on electroencephalograms (EEGs); an unremarkable pregnancy, labor, and perinatal course; a favorable response to antiepilepsy drugs, preferably monotherapy; and a normal cognitive outcome. The clinical features of seizures, EEG correlates, response to medications, developmental outcome, and family history were analyzed. Twenty-five infants fulfilled the inclusion criteria, presenting at ages 4 to 36 months (mean 17 months) with recurrent generalized clonic seizures, which were commonly short-lived, lasting up to 5 minutes; two infants also had status epilepticus. Fourteen infants (56%) had accompanying febrile seizures, which preceded the nonfebrile seizures in 10 of them. A positive family history of seizures was found in 8 (32%) patients. Analysis of the EEG showed generalized epileptiform discharges in the form of 3 to 4 Hz spike-wave and normal background activity in 21 patients (84%), with a photosensitive response induced in 3 children. A larger group of 18 infants promptly responded to therapy, mainly valproic acid, which was terminated after 2 years, along with EEG normalization and no recurrence of seizures. A smaller group of 7 patients require prolonged therapy that keeps them seizure free; the EEG remains paroxysmal, and the seizures could recur when treatment is discontinued. All patients are presently seizure free within a follow-up period of 1.5 to 14 years. Their cognition is normal, but 12 patients have short attention and concentration spans, impulsiveness, and learning difficulties. As such, the data presented here delineate an idiopathic generalized epileptic disorder during infancy with a benign course, a rapid response to therapy, and preservation of cognitive skills that may be added to the current classification of the epileptic syndromes.

Sleep Disorders and Daytime Sleepiness in Children with Attention-Deficit/ Hyperactive Disorder

STUDY OBJECTIVES

Children with attention-deficit/hyperactive disorder (ADHD), in spite of being hyperactive, still benefit from treatment with stimulant medications. We hypothesized that children with ADHD are in fact sleepy during the day, and we sought to test it objectively.

DESIGN

Single blind comparative study

SETTING

University medical center

PARTICIPANTS

Thirty-four children with a previous diagnosis of ADHD (mean age +/- SD, 12.4 +/- 4.6 years) and 32 matched controls (mean age, 12.0 +/- 3.6 years).

INTERVENTIONS

N/A.

MEASUREMENTS

All participants underwent a full-night polysomnographic study followed by a multiple sleep latency test (MSLT).

RESULTS

Sleep latency, total sleep time, and sleep efficiency were comparable between the groups, yet children with ADHD were significantly sleepier during the day than those in the control group (mean MSLT score of 21.9 +/- 5.5 minutes versus 27.9 +/- 2.0 minutes, P < .005). Of the children with ADHD, 17 (50%) had signs of sleep-disordered breathing, compared with 7 of the control group (22%, P < .05). Five of the ADHD group had periodic limb movements during sleep (15%) versus none in the control group. Children without sleep-disordered breathing or periodic limb movements during sleep had the lowest nocturnal sleep efficiency and total sleep time.

CONCLUSIONS

We conclude that children with ADHD demonstrate objective daytime somnolence, which may explain the beneficial effects of treatment with stimulant medications. Primary sleep disorders, especially sleep-disordered breathing and periodic limb movement disorder, should be looked for in children with ADHD.

[Childhood-onset epileptic blindness--clinical correlates and outcomes]

AIM

Acute blindness is a rare presentation of epileptic disorders referring to loss of sight without loss of consciousness corroborating with epileptic discharges recorded on the EEG. We summarized the pertinent literature on childhood-onset epileptic blindness. We also report on our overall experience with 26 children having developed epileptic amaurosis. This includes descriptions of the associated seizures. EEG abnormalities and reports on the response to anti-epileptic therapy as regards to resolution of blindness and control of associated seizures.

RESULTS

Our data for children with epileptic blindness is similar to previous reports regarding the reported duration of blindness and associated seizures, as well as the overall response to therapy and outcome. In our study, 25 children experienced acute episodes of complete visual obscuration lasting for 1-10 minutes and one 4-month-old infant had blindness from birth, representing status epilepticus amauroticus. Ten patients had accompanying generalized seizures, with a photosensitive response recorded in three cases. All of these children were treated with valproic acid regaining full vision and eight became seizure free. Ten children had accompanying focal motor seizures and unilateral temporo-posterior epileptic discharges recorded on EEG and two additional cases had isolated blindness and focal discharges. All 12 children were treated with carbamazepine, regaining full vision and complete seizure control in eleven. One infant with status epilepticus amauroticus since birth, secondary to a persistent epileptic focus over the right central-posterior areas, regained full vision following resection of an area of cortical dysplasia at the age of 8 months. Four additional children had the constellation of migraine headaches, focal motor seizures and complete blindness along with occipital EEG discharges, compatible with the syndrome of late-onset benign childhood epilepsy with occipital paroxysms (Gastaut syndrome). They were treated with carbamazepine and all became asymptomatic within a period of 1-4 years.

CONCLUSIONS

Analysis of the literature, in addition to our overall experience, indicates that epileptic blindness in children is associated with a favorable outcome providing prompt diagnosis and treatment of the associated seizures or epileptic syndrome. This resulted in complete and long-standing resolution of blindness in all children together with satisfactory control of seizures. As such, we recommend a prompt EEG in any child presenting acute visual obscuration, even in the absence of additional overt epileptic phenomena.

Prevalence and risk of sleep disturbances in adolescents after minor head injury

Sleep disturbances were reported in patients during the acute stage after minor head injury, and for some of these patients, the disturbances may become chronic. The purpose of the present study was to assess the prevalence and risk factors of the long-term sleep disturbances in adolescents after minor head injury. Unselected adolescents (98) who had experienced a minor head injury 0.5-6 years before the institution of the study and 80 matched control subjects were interviewed and completed a detailed questionnaire. The prevalence of sleep disturbances was significantly larger among adolescents who experienced minor head injury compared with the control subjects (28% versus 11%, P < 0.05). Within the study group, those who developed long-term sleep disturbances manifested a greater body mass index (20.8 +/- 4.0 vs 18.4 +/- 2.8 kg/m(2), P = 0.005) and poorer parental education (fathers 11.0 +/- 4.0 vs 13.4 +/- 3.0 years, mothers 11.8 +/- 3.3 vs 13.2 +/- 2.9 years, P < 0.05 for both), compared with those who did not develop sleep disturbances. Our data indicate that subjective sleep disturbances may be evident in a fairly high percentage of adolescents after minor head injury, up to 28%, suggesting that minor head injury may not be as benign as previously estimated. Risk factors include heavier body mass and poorer parental education.

Neurocristopathies presenting with neurologic abnormalities associated with Hirschsprung's disease

Neurocristopathies are a group of diverse disorders resulting from defective growth, differentiation, and migration of the neural crest cells. Hirschsprung's disease, namely aganglionic megacolon, is the consequence of defective migration of neural crest cells on to the colonic submucosa and is therefore considered a neurocristopathy. We report on four children in whom was diagnosed a neurocristopathy, associating Hirschsprung's disease with a wide spectrum of neurologic abnormalities. The patients included two children presenting the phenotypic features of the Goldberg-Shprintzen syndrome: distinct dysmorphic facial features, microcephaly, and mental retardation, along with agenesis of the corpus callosum and cortical malformations associated with intractable seizures in one child. The third newborn presented with the Haddad syndrome: short-segment Hirschsprung's disease associated with the congenital central hypoventilation syndrome requiring permanent artificial ventilation. In the fourth child, absence of the corpus callosum was associated with mild dysmorphic features, borderline cognitive abilities, and attention-deficit disorder. Therefore, awareness of a possible neurocristopathy associated with neurologic abnormalities should be taken into account in any patient newly diagnosed with Hirschsprung's disease to detect the abnormalities early and promptly manage them. A thorough neurologic examination and a developmental assessment, including magnetic resonance imaging of the brain and electroencephalography, should be performed for any child presenting with an aganglionic megacolon, especially those presenting with seizures, developmental delay, or even congenital hypoventilation.

Outcome of severe Guillain-Barré syndrome in children: comparison between untreated cases versus gamma-globulin therapy

The objective of this study was to assess retrospectively the outcome of children with severe Guillain-Barré syndrome (GBS) treated either with intravenous immunoglobulins (IVIG) versus practically untreated cases by a known beneficial agent. Twenty-three children with severe GBS who became bedridden (i.e., Motor Disability Grading Scale [MDGS] grade of at least 4) were analyzed. Fifteen children were treated with IVIG and eight children comprised the nontreatment group: five on supportive therapy and three treated previously with oral steroids found ineffective in GBS. IVIG was administered at a dosage of 1 g/kg daily for 2 days under constant monitoring, with no adverse effects requiring cessation of therapy. Improvement by 1 grade on the MDGS after IVIG therapy was achieved in the IVIG group after a mean of 10.17 days (median, 8 days), and patients started walking independently after a mean of 30.35 days (median, 20.5 days). Improvement by 1 grade on the MDGS was achieved in the nontreatment group after a mean of 22.3 days (median, 20.3 days), and they started to walk independently after a mean of 113.3 days (median, 100 days). A significant difference could not be delineated between both groups, given the rather small number of children in each group. These results indicate a possible beneficial effect of IVIG in severe childhood-onset GBS compared with the nontreated group of children. The authors therefore recommend using IVIG as the first-line drug in such cases, which warrant further approval after double-blind controlled studies of using different IVIG regimens or combined with plasmapheresis and steroids.

Favorable outcome of epileptic blindness in children

Acute blindness is a rare presentation of epileptic seizures, referring to loss of sight without loss of consciousness associated with electroencephalographic (EEG) epileptic discharges, mainly representing an ictal phase but also either pre- or postictal. We report a series of 14 children with documented epileptic blindness, describing the accompanying fits and thereafter the response to therapy to resolve the blindness and control associated seizures. All patients experienced episodes of acute complete visual obscuration lasting for 1 to 10 minutes. Seven patients hadaccompanying generalized seizures, with a photosensitive response recorded in three of them. All of these seven children were treated with valproic acid, regaining full vision, and six of them became seizure free. Three patients with acute blindness who had accompanying focal motor seizures and unilateral temporooccipital posterior epileptic discharges were treated with carbamazepine regained full vision and complete seizure control. Four additional children had the constellation of migrainous headaches, focal motor phenomena, and complete blindness, along with occipital discharges compatible with Gastaut syndrome, benign childhood epilepsy with occipital paroxysms. All four patients were started on carbamazepine and became asymptomatic. Our overall experience suggests that epileptic blindness in children is associated with a favorable outcome when promptly diagnosed and treated appropriately, resulting in complete resolution of blindness in all children and satisfactory control of seizures in most of them. We therefore recommend performing a prompt EEG in any child presenting with acute visual obscuration, even in the absence of other epileptic phenomena.

Carbamazepine versus sulthiame in treating benign childhood epilepsy with centrotemporal spikes

We compared the therapeutic efficacy of carbamazepine versus sulthiame in patients with benign childhood epilepsy with centrotemporal spikes. Drug efficacy was evaluated only in those patients who initiated treatment with any drug after at least three seizures. Thirty-eight patients who received carbamazepine and 18 patients who received sulthiame were included in the analysis. Cessation of seizures was observed in 73.6% of the former and in 66.7% of the latter (P = not significant). Five of eight patients who were switched to sulthiame after failing carbamazepine became seizure free, whereas none of the three patients who failed sulthiame became seizure free after being switched to carbamazepine. The rate of drug discontinuation owing to adverse reaction was 15% in carbamazepine and 14.3% in sulthiame. Normalization of interictal epileptiform activity on electroencephalography was seen more often following treatment with sulthiame (71%) than with carbamazepine (42%) (P = not significant). No significant differences between these two medications were found in the treatment of benign childhood epilepsy with centrotemporal spikes in this small patient sample.

Severe hypersomnolence after pituitary/hypothalamic surgery in adolescents: clinical characteristics and potential mechanisms

OBJECTIVES

After resection of hypothalamic/pituitary tumors, children are at risk for development of hormonal deficiencies, obesity, and hypersomnolence. However, the prevalence and pathophysiology of these complications are unclear. The purpose of this study was to assess the prevalence and severity of hypersomnolence in children after resection of pituitary tumors and to study the potential factors that contribute to this sleepiness if present. We further hypothesized that decrements in orexin levels may contribute to the sleepiness.

METHODS

Six children who underwent hypothalamic/pituitary surgery were identified. Five of these patients and 5 matched control subjects underwent overnight polysomnography followed by a multiple sleep latency test. Children who had a primary sleep disorder (eg, obstructive sleep apnea) underwent treatment and were restudied subsequently (n = 2). Blood levels of pituitary hormones were measured. Blood and cerebrospinal fluid (CSF) were drawn from 4 patients and 3 control subjects to measure orexin levels.

RESULTS

Endocrine control was appropriate in all children. Although patients had longer sleep duration but similar sleep efficiency than control subjects, relatively severe daytime somnolence was present (mean sleep latency: 10.3 +/- 5.3 minutes vs 26.2 +/- 1.1 minute in control subjects). Sleepiness did not correlate with body mass index or age. Furthermore, serum and CSF orexin levels did not differ between patients and control subjects.

CONCLUSIONS

Severe daytime sleepiness is frequent among children who undergo pituitary/hypothalamic surgery and does not seem to result from inappropriate cortisol or thyroxine replacement, disturbed nocturnal sleep, or low levels of orexin in the serum or CSF. We therefore speculate that other, unidentified neurohormonal mechanisms may mediate the excessive sleepiness of these patients.

Epilepsia partialis continua associated with widespread gliomatosis cerebri

We report an uncommon association of intractable epilepsia partialis continua that was the main presentation of widespread gliomatosis cerebri in two females. Both children had a preceding prolonged secondary generalized seizure 2-4 months before the evolution of epilepsia partialis continua, including recurrent clusters of left-sided myoclonic twitching and sensory impairment. During these events, the children remained fully alert. These seizures were corroborated by prolonged focal epileptic spike/wave discharges evident on the electroencephalograms. Cerebral magnetic resonance imaging in the first patient demonstrated a wide area of increasing signals over the right frontocentral regions, along with diffuse cortical-subcortical infiltration impinging on the left hemisphere. In the second patient a cortical lesion was suspected. Evaluation for Rasmussen's encephalitis, focal cortical dysplasia, or a gliomatous process was conducted; the patients underwent a stereotactic brain biopsy in which the histologic findings were compatible with gliomatosis cerebri with diffuse widespread infiltration of glioma cells with no constitution of a circumscribed tumor mass. The first patient was treated with cranial radiation, chemotherapy, steroids, and combined antiepileptic therapy. The focal seizures gradually but markedly decreased in frequency, and sensory impairment abated within 18 months after establishment of the diagnosis and ensuing therapy. Cognition remains intact. The second female died 2 years after presentation despite massive chemotherapy and antiepileptic medications. Although rare, gliomatosis cerebri should be taken into account in the differential diagnosis of epilepsia partialis continua in children to facilitate a rapid diagnosis and initiation of prompt treatment of this rare disorder that may respond to a concurrent effective combination of cranial radiation, chemotherapy, and antiepileptic medications.

Outcome of severe encephalomyelitis in children: effect of high-dose methylprednisolone and immunoglobulins

Acute encephalomyelitis in children refers to an insult of cortical white matter leading to acute disseminated encephalomyelitis, insult of the spinal cord leading to multifocal myelopathy, or a combined form of encephalomyelitis. We report here the clinical presentations and outcome of 16 children with severe acute encephalomyelitis analyzing the effect of high-dose methylprednisolone or intravenous immunoglobulins, administered separately or in combination. Five children developed acute disseminated encephalomyelitis alone, eight developed severe multifocal myelopathy accompanied in two of them by radiculoneuropathy, and three developed the most severe form of combined encephalomyeloradiculoneuropathy. The indications for treatment with either high-dose methylprednisolone, intravenous immunoglobulin, or a combination of the two were severe acute disseminated encephalomyelitis, visual loss, or severe flaccid weakness accompanied by bladder and bowel incontinence. Overall, 10 children had remarkably responded to high-dose methylprednisolone alone and recovered within 10 days. One patient with severe myelopath, developing paraplegia, who failed oral corticosteroids completely recovered following intravenous immunoglobulin. Of the isolated acute disseminated encephalomyelitis group, all patients were initially treated with high-dose intravenous methylprednisolone and recovered within 10 days, including visual remission in the child with severe optic neuritis. All six children with solitary severe multifocal myelopathy were treated with high-dose methylprednisolone alone and recovered within the first week. Two patients had severe myeloradiculoneuropathy and were therefore treated with combined high-dose methylprednisolone and intravenous immunoglobulin: one remains paraplegic, whereas the second was ventilated for 3 weeks and recovered after 2 months. The three children with the most severe form of encephalomyeloradiculoneuropathy were treated with combined high-dose methylprednisolone and intravenous immununoglobulin; two remain severely handicapped, of whom one is paraplegic, and the third unexpectedly recovered within 3 months. Therefore, our experience indicates that either high-dose methylprednisolone or intravenous immunoglobulin, given separately or combined, may be efficacious in severe debilitating pediatric-onset acute encephalomyelitis. In children with the most severe form of encephalomyeloradiculoneuropathy, we suggest initially administering high-dose methylprednisolone and intravenous immunoglobulin combined, given the poorer outcome of our patients with combined severe central and peripheral demyelination.

Near reflex accommodation spasm: unusual presentation of generalized photosensitive epilepsy

We report on a 9 year old girl admitted with prolonged and recurrent episodes of near reflex accommodation spasm (NRAS), which was the sole clinical manifestation of primary generalized photosensitive epilepsy. Four days prior to admission, the patient started to experience intermittent episodes of adduction of both eyes and miosis, namely near reflex accommodation spasm, which apparently became fixed three hours prior to admission, with no other perturbations. On examination she was fully alert showing a fixed NRAS, but otherwise unremarkable neurological examination. Time locked with NRAS, the EEG demonstrated generalized spike/wave discharges, also induced with photic stimuli, compatible with generalized photosensitive epilepsy. Assuming an epileptic etiology for the diagnosed NRAS, she was started on a small dose of valproate and became asymptomatic within the first day of treatment, along with EEG normalization. She remained asymptomatic within seven months when the valproic acid was erroneously discontinued. After a few days she began experiencing short lived episodes of NRAS, which could also be induced by photic stimulation and a concurrent EEG again demonstrated generalized epileptiform discharges. Searching the literature, this is the first report associating generalized photosensitive epilepsy with NRAS, and hence complete resolution of NRAS in response to antiepileptic therapy along with normalization of the EEG. An epileptic disorder should be therefore taken into account in any patient with new onset NRAS, especially when other epileptic phenomena are absent.

Clinical characteristics and muscle pathology in myopathic mitochondrial DNA depletion

Four nonrelated children with myopathic mitochondrial DNA depletion are described. Two of them initially had normal motor development and two had mild motor delay. Motor arrest and regression started at age 6 to 21 months. All four had mitochondrial DNA:nuclear DNA ratios reduced to 16 to 22% of the control mean and mutations in their mitochondrial thymidine kinase 2. Muscle pathology was genotype related: homozygosity for a missense mutation at position 181 was associated with severe myopathic changes, including marked variation in muscle fiber size, myofiber necrosis, regeneration, and interstitial fibrosis, whereas homozygosity for a missense mutation at position 90 was associated with essentially normal muscle histology. No ragged red fibers were detected in any study child. Mitochondrial DNA depletion should be considered in children with myopathy, worsening hypotonia, motor regression, and death during infancy or early childhood. The severity of pathologic findings on muscle biopsy is variable and may correlate with specific mutations and thymidine kinase 2 protein residual activity.

Valproic acid therapy inducing absence status evolving into generalized seizures

The authors herein present two children with mild absence epilepsy, having intermittent absences, who developed absence status evolving into atonic generalized seizures and drop attacks along with progressive disorientation induced by relatively small doses of valproic acid. Consciousness and awareness were intact before the introduction of valproic acid. Both children, after the first dose of valproic acid, developed prolonged and recurrent clusters of absences, which became prolonged, with drop attacks occurring in one patient associated with progressive disorientation. The electroencephalogram concurrently demonstrated prolonged spike-wave discharges, along with disturbance of background activity. Discontinuation of valproic acid resulted in immediate cessation of the prolonged and repetitive clusters of absence episodes and disappearance of drop attacks, along with sensorium clearing. In conclusion, although uncommon, a possible induction of absence status and even atonic seizures by valproic acid should be taken into account and properly managed by abrupt discontinuation of the drug.

Congenital muscular dystrophy in Israeli families

Twelve patients from 11 Israeli families with congenital muscular dystrophy were evaluated between 1991 and 2001. There were six males and six females, of whom six were merosin negative and six were merosin positive. Serum creatine kinase levels were highly elevated in the merosin-negative group. Four of the children were cognitively normal but nonambulant. Two had unusual clinical findings of severe cognitive and motor developmental dysfunction. Four infants in the merosin-positive group who had normal serum creatine kinase levels had early-onset severe motor weakness and died within the first year of life owing to ventilatory insufficiency. The other two were ambulant and had normal cognitive development and elevated serum creatine kinase levels. Noteworthy, two of the six children with merosin-negative congenital muscular dystrophy had cognitive impairment, and four of the six children with merosin-positive congenital muscular dystrophy had a severe form of the disease with ventilatory insufficiency and death during infancy.

[Visual field disturbances in epileptic patients treated with vigabatrin (sevril)]

Vigabatrin, one of the newer anti-epileptic drugs (AED), whose effect is mediated via elevated levels of brain GABA, has proved to be effective in drug resistant partial seizures and infantile spasms. Recently, visual field constriction was found in up to 30% of adults, whereas information for the pediatric age group is sparse. We examined 24 visually-asymptomatic children, ages 3.5-18 years, treated for 3.01.6 years at doses of 25-90 mg/kg. These children underwent an ophthalmologic examination, visual evoked potentials, electroretinogram and when possible, perimetry. Over half of the children had at least one abnormal test and 11/17, who were able to undergo perimetric studies, had symmetrical, nasal visual field constriction. In view of the gravity and prevalence of visual field constriction, use of the AED vigabatrin should be weighed against its clinical benefits.

Benign childhood epilepsy with centrotemporal spikes: clinical characteristics and identification of patients at risk for multiple seizures

This study aimed to characterize patients diagnosed as having benign childhood epilepsy with centrotemporal spikes and few seizures and compare them with patients with benign childhood epilepsy with centrotemporal spikes with multiple seizures. The medical files of 87 consecutive patients with benign childhood epilepsy with centrotemporal spikes were reviewed and data on gender, age at disease onset, duration of the disease, number of seizures, seizure semiology, and electroencephalographic and neuroimaging findings were analyzed. The mean age at disease onset was 8 years. The mean duration of the disease was 2 years. Eighteen percent of the patients had more than 20 seizures each, whereas 24% had 1 to 3 seizures each. The only predictor for a disease course with multiple seizures was an onset prior to 3 years of age.

Winging of the scapula in a child with hereditary multiple exostoses

A female, 10 years of age, with hereditary multiple exostoses presented with shoulder drop and asymmetry. The results of neurologic examination were normal and winging was not accentuated by active maneuvers of the shoulder. Scapular exostosis was demonstrated to be the structural cause of scapular winging. Only a few cases of children with scapular winging caused by scapular tumors have been reported. However, tumors of the scapula should be excluded in children with static winging of the scapula.

White blood cell count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women: atherosclerosis risk in communities study

The authors examined the association between white blood cell (WBC) count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in 13,555 African-American and White men and women from the Atherosclerosis Risk in Communities (ARIC) Study. Blood was drawn at the ARIC baseline examination, beginning in 1987-1989. During an average of 8 years of follow-up (through December 1996), there were 488 incident coronary heart disease events, 220 incident strokes, and 258 deaths from cardiovascular disease. After adjustment for age, sex, ARIC field center, and multiple risk factors, there was a direct association between WBC count and incidence of coronary heart disease (p < 0.001 for trend) and stroke (p for trend < 0.001) and mortality from cardiovascular disease (p for trend < 0.001) in African Americans. The African Americans in the highest quartile of WBC count (> or =7,000 cells/mm(3)) had 1.9 times the risk of incident coronary heart disease (95% confidence interval (CI): 1.19, 3.09), 1.9 times the risk of incident ischemic stroke (95% CI: 1.03, 3.34), and 2.3 times the risk of cardiovascular disease mortality (95% CI: 1.38, 3.72) as their counterparts in the lowest quartile of WBC count (<4,800 cells/mm(3)). These associations were similar in Whites and in never smokers. An elevated WBC count is directly associated with increased incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women.

Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study

BACKGROUND

Retinal microvascular abnormalities reflect damage from hypertension and other vascular processes. We examined the relation of such abnormalities to incident stroke.

METHODS

A cohort of 10358 men and women (aged 51 to 72 years) living in four US communities underwent retinal photography and standard grading for retinal microvascular abnormalities. The calibres of all retinal arterioles and venules were measured after digital conversion of the photographs, and a summary arteriole-to-venule ratio (AVR) was calculated as an index of arteriolar narrowing (smaller AVR indicates greater narrowing). Cases of incident stroke admitted to hospital were identified and validated by case record reviews.

FINDINGS

Over an average of 3.5 years, 110 participants had incident strokes. After adjustment for age, sex, race, 6-year mean arterial blood pressure, diabetes, and other stroke risk factors, most retinal microvascular characteristics were predictive of incident stroke, with adjusted relative risks of 2.58 (1.59-4.20) for any retinopathy, 3.11 (1.71-5.65) for microaneurysms, 3.08 (1.42-6.68) for soft exudates, 2.55 (1.27-5.14) for blot haemorrhages, 2.26 (1.00-5.12) for flame-shaped haemorrhages, and 1.60 (1.03-2.47) for arteriovenous nicking. The relative risk of stroke increased with decreasing AVR (p=0.03). The associations were similar for ischaemic strokes specifically, and for strokes in individuals with hypertension, either with or without diabetes.

INTERPRETATION

Retinal microvascular abnormalities are related to incident stroke. The findings support a microvascular role in the pathogenesis of stroke. They suggest that retinal photography may be useful for cerebrovascular-risk stratification in appropriate populations.

Genotypic variation of HIV-1 reverse transcriptase and protease: comparative analysis of clade C and clade B

OBJECTIVE

To compare drug-resistant variants from untreated (naive) and treated patients infected with clade B or C virus.

METHODS

Consecutive samples (165) from patients throughout Israel were analyzed. All those in the treated group were failing highly active antiretroviral therapy.

RESULTS

There were 87 clade B (14 naive) and 78 clade C (20 naive) [corrected] with significant differences in the prevalence of known drug-resistance mutations between the clades: in naive patients in the protease region M36I 7% and 95% (P < 0.0001), K20R 0% and 27% (P = 0.063), A71V 18% and 0% (P = 0.063), M46I 0% and 13%, and V77I 18% and 0% (P = 0.063), respectively, and in the reverse transcriptase region A98G/S 0% and 20% (P = 0.12), respectively. Most clade C viruses also showed significant differences from clade B consensus sequence at additional protease sites: R41K 100%, H69K/Q 85%, L89M 95% and I93L 80% (P < 0.0001). There were also significant differences (P < 0.03 to < 0.0001) in treated patients in clades B and C: in the protease region L10I 40% and 12%, M36I 26% and 95%, L63P 67% and 40%, A71I 38% and 7%, G73I and V77I 18% and 0%, I84V 16% and 3%, and L90M 40% and 12%, respectively; in the reverse transcriptase M41L 41% and 17%, D67N 41% and12%, K70R 30% and 7%, T215Y 48% and 29%, K219Q 21% and 7%, and A98G/S 3% and 24%, respectively.

CONCLUSION

Significantly differences between clade B and C viruses may be associated with development of differing resistance patterns during therapy and may affect drug utility in patients infected with clade C.