Nonconvulsive status epilepticus: EEG analysis in a large series

We analyzed EEG characteristics comprehensively in a large series of nonconvulsive status epilepticus (NCSE) cases. Eighty-five ictal episodes in 78 patients were analyzed. The ictal discharges were generalized (group G) in 59 episodes (69%), diffuse with focal predominance (group GF) in 15 (18%), and focal (group F) in 11 (13%). The morphologies and patterns of persistence varied greatly. Frequency of ictal discharge was also variable and was almost always < 3 Hz. Demonstration of focal epileptic features in response to intravenous (i.v.) diazepam (DZP) and the presence of interictal focal epileptiform discharges in some cases in groups G and GF suggested possible focal onset secondarily generalized in these cases. This study suggests that electrographically NCSE is a highly heterogeneous epileptic state, and i.v. DZP may serve as a valuable diagnostic tool in differentiating generalized from focal onset NCSE.

Identification, characterization and purification of a 160 kD bumetanide-binding glycoprotein from the rabbit parotid

We demonstrate the presence of a 160 kD protein in rabbit parotid basolateral membranes that can be labeled with the irreversible sulfhydryl reagent [14C]-N-ethylmaleimide in a bumetanide-protectable fashion. The specificity of this labeling, and our previous evidence for the existence of an essential sulfhydryl group closely associated with the bumetanide-binding site on the parotid Na(+)-K(+)-Cl-cotransporter (J. Membrane Biol. 112:51-58, 1989), provide strong evidence that this protein is a part or all of the parotid bumetanide-binding site. When this protein is treated with endoglycosidase F/N-glycosidase F to remove N-linked oligosaccharides, its apparent molecular weight decreases to 135 kD. The pI of this deglycosylated protein is approximately 6.4. The bumetanide-binding protein was purified using two preparative electrophoresis steps. First, a Triton X-100 extract enriched in this protein was run on preparative electrophoresis to obtain fractions containing proteins in the 160 kD range. These were then deglycosylated with endoglycosidase F/N-glycosidase F and selected fractions were pooled and rerun on preparative electrophoresis to obtain a final 135 kD fraction. The enrichment of the bumetanide-binding protein in this final 135 kD fraction estimated from [14C]-N-ethylmaleimide labeling was approximately 48 times relative to the starting membrane extract. Since the bumetanide-binding site represents approximately 2% of the total protein in this starting extract, this enrichment indicates a high degree of purity of this protein in the 135 kD fraction.

CT of retroperitoneal extension of hepatoma mimicking adrenal tumor

OBJECTIVE

The anatomy of the superior aspect of the renal fascia is still controversial. We recently saw three cases of hepatoma extension into perirenal space and believed the bare area of the liver communicated with the perirenal space.

MATERIALS AND METHODS

We reviewed the CT of the three cases of hepatoma with retroperitoneal extension. One was pedunculated and the others were exophytic.

RESULTS

One pedunculated hepatoma was operated upon while we were under the impression that it was an adrenal carcinoma. The others were initially mistaken for a metastatic or primary adrenal carcinoma.

CONCLUSION

The bare area of the liver opens widely into the superior aspect of the perirenal space and permits easy extension of pedunculated or exophytic masses of the liver arising in this location, mimicking and adrenal mass.

Outcomes of bacterial meningitis in children: a meta-analysis

We abstracted the results of all English language reports of the outcomes of bacterial meningitis published after 1955. We used hierarchical Bayesian meta-analysis to determine the overall and organism-specific frequencies of death and persistent neurologic sequelae in children 2 months to 19 years of age. A total of 4920 children with acute bacterial meningitis were included in 45 reports that met the inclusion criteria. Children described in the 19 reports of prospectively enrolled cohorts from developed countries had lower mortality (4.8% vs. 8.1%) and were more likely to have no sequelae (82.5% vs. 73.9%). In these 19 studies 1602 children were evaluated for at least 1 sequela after hospital discharge. The mean probabilities of these sequelae were: deafness, 10.5%; bilateral severe or profound deafness, 5.1%; mental retardation, 4.2%; spasticity and/or paresis, 3.5%; seizure disorder, 4.2%; and no detectable sequelae, 83.6%. Mean probabilities of outcomes varied significantly by etiologic bacteria, e.g. mortality: Haemophilus influenzae, 3.8%; Neisseria meningitis, 7.5%; Streptococcus pneumoniae, 15.3%.

Midline spikes: is it another benign EEG pattern of childhood?

Clinical and electrographic features were retrospectively studied in 57 patients with midline (Fz, Cz, Pz) spikes as the only epileptiform activity in their EEG to determine possible predictors of outcome. Our study confirmed previous reports of early age of onset, activation by sleep, and Cz as the most frequent spike location. In contrast to previous studies with smaller numbers of patients, midline spikes were more common in males and most often associated with partial complex seizures and were not activated by sleep at an older age. Of the 29 patients who were followed for 6 months to 9 years, only 15 (52%) achieved good seizure control. Although a tendency toward a poor outcome was noted with several independent variables (positive family history of epilepsy, later age of seizure onset, abnormal EEG background activities, abnormal neuroimaging, abnormal neurologic examination), none was of statistical significance. This study suggests that epilepsy with midline spikes is not necessarily benign and that future studies with larger patient groups may be necessary to identify factors that influence prognosis.

Secretagogue-induced 86Rb+ efflux from bovine parotid is HCO3- dependent

Muscarinic agonist (carbachol)-induced K+ loss from a bovine parotid mince was studied using 86Rb+ as a K+ marker. In contrast to our previous studies with the rat parotid [Am. J. Physiol. 261 (Gastrointest. Liver Physiol. 24): G111-G118, 1991] in which both Cl(-)-dependent and HCO3(-)-dependent components of carbachol-induced 86Rb+ efflux were observed, no significant evidence for Cl(-)-dependent 86Rb+ loss was detected in the bovine parotid. HCO3(-)-dependent agonist-induced 86Rb+ loss was blunted by K+ and Cl- channel blockers and by removal of extracellular Ca2+, consistent with the hypothesis that this 86Rb+ loss occurs via a Ca(2+)-activated K+ channel and that this cation loss serves to electrically balance the concomitant loss of HCO3- via an electrically conductive pathway, presumably an apical anion channel. Acetate, formate, and propionate could substitute for HCO3-. Interpreted in terms of current models of salivary fluid secretion, which hypothesize that the production of fluid is secondary to anion secretion accompanied by an electrically coupled K+ loss, these results indicate that salivary production in the bovine parotid is driven almost exclusively by acinar HCO3- secretion.

Histologic study of chronic active hepatitis C; comparison with chronic active hepatitis B

Reports on the histologic findings of chronic active hepatitis C (CAH-C) have been rare, and the characteristic histologic findings of CAH-C have been not yet determined. To compare the differences in the histologic findings between CAH-C and chronic active hepatitis B (CAH-B) group, we analyzed the histologic findings of 19 patients with CAH-C, who had positive tests for HCV-antibody by EIA, and 19 patients with CAH-B who had negative tests for HCV-antibody but positive tests for HBsAg by RIA. Histologic features were analyzed between the CAH-C and CAH-B groups using a scoring system which is modified from Knodell's histologic activity index-looking at portal inflammation, periportal necroinflammation, portal fibrosis, focal necrosis, regeneration, polyploid nuclear change, sinusoidal lymphocytic reaction and fatty change. Portal inflammatory cell infiltrations with prominent lymphocytes and follicular arrangement were more frequent in the CAH-C group (10 of 19 cases) than in the CAH-B group (5 of 19 cases). Severe sinusoidal lymphocytic reactions were also more prominent in the CAH-C group (11 of 19 cases) than in the CAH-B group (6 of 19 cases). However, periportal necroinflammation, portal fibrosis, focal hepatic necrosis, regeneration and polyploid nuclear changes were more prominent in the CAH-B group than in the CAH-C group. In conclusion, follicular portal inflammation and severe sinusoidal lymphocytic reactions were common histologic findings in serologically proven CAH-C when compared to CAH-B.

Viral small nuclear ribonucleoproteins bind a protein implicated in messenger RNA destabilization

Herpesvirus saimiri (HVS) is one of several primate viruses that carry genes for small RNAs. The five H. saimiri-encoded U RNAs (HSURs) are the most abundant viral transcripts expressed in transformed marmoset T lymphocytes. They assemble with host proteins common to spliceosomal small nuclear ribonucleoproteins (snRNPs). HSURs 1, 2, and 5 exhibit sequences at their 5' ends identical to the AUUUA motif, which targets a number of protooncogene, cytokine, and lymphokine mRNAs for rapid degradation. We show that a 32-kDa protein previously demonstrated to bind to the 3' untranslated region of several unstable messages can be UV crosslinked specifically to HSUR 1, 2, and 5 transcripts in vitro, as well as to endogenous HSUR snRNPs. Our results suggest an unusual role for these viral snRNPs: HSURs may function to attenuate the rapid degradation of certain cellular mRNAs, thereby facilitating viral transformation of host T lymphocytes.

Mechanism of secretagogue-induced HCO3- and Cl- loss from rat parotid acini

The Cl(-)- and HCO3(-)-dependent components of muscarinic agonist (carbachol)-induced K+ loss from a rat parotid mince were studied using 86Rb+ as a K+ marker. Both components of 86Rb+ loss were blunted by K+ and Cl- channel blockers and by removal of extracellular Ca2+, consistent with the hypothesis that 86Rb+ loss occurs via a Ca(2+)-activated K+ channel and that this cation loss serves to electrically balance a concomitant loss of the corresponding anion via one or more conductive pathways (channels). Two tissue "pools" of 86Rb+ were observed, a carbachol-sensitive pool and a carbachol-insensitive pool (approximately 70 and approximately 30% of the total 86Rb+ content, respectively). There was no evidence for a time-dependent desensitization of the muscarinic response of the carbachol-sensitive pool. Cl(-)-dependent 86Rb+ loss was not affected by HCO3- addition, suggesting that both Cl- and HCO3- secretion are accompanied by 86Rb+ loss from the same pool and thus occur from the same cells. HCO3(-)-dependent 86Rb+ loss was not enhanced by lowering the extracellular Na+ concentration, indicating that the HCO3- exit pathway is not a Na(+)-HCO3- symport. The data are consistent with the postulate that Cl- and HCO3- are secreted by rat parotid acinar cells via the same or very similar conductive transport pathways in response to muscarinic stimulation.

Somato-somatic referred pain caused by suprasegmental spinal cord tumor

Tactile stimulation of a coin-sized area in a T-2 dermatome consistently triggered a lancinating pain in the ipsilateral C-8 dermatome in a 38-year-old woman. The SEP and an MRI led to a diagnosis of a tumor at the left cervico-medullary junction, much higher than the clinically suspected level. Surgical exploration revealed an exophytic glioma, and the pain was abolished postoperatively. Ephaptic transmission at the tumor site was suspected as a pathophysiologic mechanism.

Reactive occipital epileptiform activity: is it benign?

Occipital epileptiform activity that is almost continuous and reactive to eye opening has been associated with a childhood epilepsy syndrome and basilar migraine with seizures. An association of these syndromes with a benign course had been disputed. In this study, a retrospective investigation of reactive occipital epileptiform activity (ROEA) was performed to determine the prognostic value of this distinctive EGG pattern. The EEG and hospital record of patients with ROEA were reviewed with an observation period of 6 months to 8 years. The patients were divided into good and poor outcome groups based on response to treatment. Of 33 patients, 12 (36.4%) had complete seizure control; 21 (63.6%) continued to have poorly controlled seizures. Only 3 (9.1%) patients were able to discontinue antiepileptic drugs (AEDs) without seizure recurrence. Analysis of clinical and EEG variables showed that a history of perinatal difficulties, abnormal neurologic findings, and abnormal EEG background activities occur significantly more frequently in the poor outcome group. This study suggests that ROEA is not uniformly associated with a benign course and that other factors are involved in determining prognosis of the epilepsy.

Circulating immune complexes and cell-mediated immunity in patients with hepatitis B virus associated liver diseases

The prevalence of circulating immune complexes (CIC), their role and their relationship to cell-mediated immunity in patients with hepatitis B virus associated liver disease are still controversial. This study was designed to investigate the prevalence of CIC and their relationship to viral markers, to subsets of peripheral blood T lymphocytes and to suppressor cell activity in patients with hepatitis B virus associated liver diseases. CIC were positive in 29.3% of 41 healthy HBsAg carriers, 37.8% of 88 patients with hepatitis B virus associated liver diseases, and 15% of 41 healthy subjects by the platelet aggregation test (PAT). The prevalence of CIC in patients with acute hepatitis (40.0%) and in those with cirrhosis (61.5%) was significantly higher than in normal controls (p less than 0.05, p less than 0.005 respectively). There was no correlation between the titer of CIC and serum HBsAg titer or the status of HBeAg, and no significant decrease in the peripheral blood lymphocyte CD4/CD8 ratio in healthy HBsAg carriers (1.39 +/- 0.31) and in patients with liver diseases (1.40 +/- 0.54) compared to the normal controls (1.48 +/- 0.31). Concanavalin A induced suppressor cell activity on IgG producing cells was impaired in healthy HBsAg carriers (34.9%) (p less than 0.005) and in patients with liver diseases (25.3%) (p less than 0.0001), and this change was prominent in patients with chronic active hepatitis and cirrhosis (p less than 0.0001). And there was a significant reverse correlation between concanavalin A induced suppressor cell activity on IgG-producing cells and the titer of CIC in PAT positive patients with hepatitis B virus associated liver diseases. In conclusion, it was suggested that defective suppressor cell function may lead to an increased B cell activation and such activity may account for the presence of CIC.

Prolonged confusion following convulsions due to generalized nonconvulsive status epilepticus

Among patients with a prolonged confusional state after convulsive seizure, we diagnosed 8 cases as generalized nonconvulsive status epilepticus. Six had a history of seizures, and 2 had new onset. The convulsive seizures were generalized in 6 and focal in two. The postictal confusion lasted up to 36 hours in the most prolonged case, and a delayed response to anticonvulsant medications occurred in all cases. The clinical symptoms ranged from mild confusion to coma. Psychiatric manifestations or automatisms were rare. The presumed etiology was due to diverse causes, but a withdrawal state was the most common. EEG demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology. These cases call attention to the fact that some prolonged confusional states following convulsive seizures are in fact due to persistent seizure activity that can be diagnosed by EEG.

Herpesvirus saimiri U RNAs are expressed and assembled into ribonucleoprotein particles in the absence of other viral genes

Marmoset T lymphocytes transformed by herpesvirus saimiri contain a set of five virally encoded U RNAs called HSUR1 through HSUR5. HSUR genes have been individually transfected into a nonlymphoid, nonsimian cell line (HeLa cells) in the absence of any other coding regions of the herpesvirus saimiri genome. The levels of HSUR1 through HSUR4 in HeLa transient-expression systems are comparable to those found in virally transformed T cells (23 to 91%). In contrast, HSUR5 is expressed at ninefold-higher levels in transfected HeLa cells. Immunoprecipitation experiments show that HSURs expressed in transfected cells bind proteins with Sm determinants and acquire a 5' trimethylguanosine cap structure, as they do in transformed T cells. HSUR1 or HSUR4 particles from transfected HeLa cells migrate between 10S and 15S in velocity gradients, identical to the sedimentation of "monoparticles" produced in virally transformed lymphocytes. We conclude from these transfection experiments that no other herpesvirus saimiri or host-cell-specific gene products appear to be required for efficient expression of the HSUR genes or for subsequent assembly of the viral U RNAs into small nuclear ribonucleoprotein particles. In lymphocytes transformed by herpesvirus saimiri, HSUR small nuclear ribonucleoprotein particles are involved in higher-order complexes that sediment between 20S and 25S. HSUR1, HSUR2, and HSUR5 dissociate from such complexes upon incubation at 30 degrees C, whereas the complex containing HSUR4 is stable to incubation.

Locally advanced unresectable gastric cancer successfully resected after neoadjuvant chemotherapy with FADE regimen

The prognosis of unresectable advanced gastric cancer is extremely poor. We tried a neoadjuvant chemotherapy in locally advanced unresectable stomach cancer diagnosed by initial explo-laparotomy. After chemotherapy with the FADE regimen (5-fluorouracil + adriamycin + cisplatin + etoposide), the patient was diagnosed clinically as a complete response state on re-staging with radiological gastrointestinal study, fiber-gastroscopy and computerized tomography. During the second-look operation, the advanced cancer was completely resected and the pathological diagnosis was early gastric cancer (EGC) type IIc, stage II (T1N2Mo).

Influence of gamma-aminobutyric acid on the changes of blood pressure in rats

This is an attempt to investigate the effect of gamma-aminobutyric acid (GABA), a well-known major inhibitory neurotransmitter in the central nervous system, on the blood pressure response in rats and to elucidate the mechanism of its action. GABA injected into a femoral vein of the rat produced a dose-related fall in blood pressure followed by a secondary pressor response. The depressor response evoked by GABA was clearly blocked by pretreatment with chlorisondamine, diazepam and picrotoxin but was unaffected by atropine, prazosin and debrisoquin. GABA-induced pressor responses were significantly attenuated by pretreatment with prazosin or picrotoxin, while not affected by atropine, diazepam, debrisoquin and chlorisondamine. These experimental data suggest that GABA causes biphasically depressor and pressor responses in rats, and that the hypotensive activity evoked by GABA may be exerted through activation of GABAergic receptors and hypertensive activity due to stimulation of the adrenergic alpha-receptors, which appears to be associated with GABAergic receptors.

Endoscopic injection sclerotherapy in patients with bleeding esophageal varices: a retrospective analysis

Endoscopic injection sclerotherapy has been accepted as the procedure of choice for patients with variceal hemorrhage. To evaluate the efficiency of endoscopic injection sclerotherapy in patients with bleeding esophageal varices, we did a retrospective study of 52 patients (non-sclerotherapy group) with bleeding esophageal varices who were admitted to hospitals and did not receive sclerotherapy and of 50 patients (sclerotherapy group) who received sclerotherapy with ethanolamine oleate. The mortality (sclerotherapy group vs. non-sclerotherapy group: 18.0% vs. 32.7%) during index hospitalization, the bleeding risk factor (the number of rebleeds per patient/month; 1.56 +/- 2.76 vs. 4.96 +/- 9.99: mean +/- SEM) and the mortality due to bleeding (14.0% vs. 36.5%) were higher in the non-sclerotherapy group than in the sclerotherapy group. Only those in Child's class C who received sclerotherapy had a significantly better survival rate than the non-sclerotherapy group (p less than 0.05). Although formal comparisons were not made because of the retrospective nature of this study, endoscopic injection sclerotherapy is effective and appears to be superior to conventional medical treatments.

Submucosal lymphatic cyst of the stomach--a case report

A submucosal lymphatic cyst is a thin-walled cyst, lined by flattened lymphatic endothelium, containing thin serous fluid. It rarely causes clinical symptoms, and it is incidentally discovered during fiberoptic panendoscopy or radiologic study in most cases. It is an extremely rare benign tumor of the stomach; however, a submucosal lymphatic cyst should be considered if a pliable and benign submucosal lesion is detected during fiberoptic panendoscopy. We report a case of submucosal lymphatic cyst of the stomach which showed a typical clinical picture. This report is the first case of submucosal lymphatic cyst of the stomach in Korea to the best of our knowledge.

A novel mechanism for the selection of isotype-specific antibody responses: the role of intestinal T cells in the regulation of IgA synthesis by the anti-suppressor circuit

Within 6 hr of immunization the serum of mice contains a unique form of processed antigen, which consists of a complex of immunoglobulin (Ig) and antigen formed in the presence of a factor derived from the anti-suppressor inducer T cell. This complex binds to and activates the anti-suppressor effector T cell, which eventually leads to the inhibition of suppressor cell function. Both of these cells are present in the spleen (SPL) and play a role in the regulation of antibody responses. The purpose of these studies was to identify the anti-suppressor T cells in gut-associated lymphoid tissue and compare their function to their splenic counterparts. Inducer cells were detected in the Peyer's patches (PP), mesenteric lymph nodes but not in the intra-epithelial lymphocytes. The effector cells, which take up the complexes, were detected in PP and lamina propria lymphocytes but not in the intraepithelial or mesenteric lymph node lymphocytes. Furthermore, the uptake of the complexes correlated with the presence of T cells bearing Ia antigens. The PP and SPL anti-suppressor cells were compared for their ability to enhance the production of IgA and IgG. The data clearly showed that the product of the inducer cell, and the effector cell it activates, not only enhanced the antigen-specific responses but also selected for isotype-specific antibody responses. Cells from SPL enhanced IgG greater than IgA, whereas cells from PP selected for IgA. Thus, the presence in PP of cells in the anti-suppressor circuit and their ability to selectively promote IgA synthesis suggest that this regulatory mechanism plays a significant role in intestinal immune responses.

Four novel U RNAs are encoded by a herpesvirus

Marmoset T lymphocytes transformed by herpesvirus saimiri contain the first virally encoded U RNAs (called HSURs) to be identified. HSURs assemble into small nuclear ribonucleoproteins of low abundance (less than or equal to 2 x 10(4) copies/cell). They bind proteins with Sm determinants and acquire a 5' trimethylguanosine cap structure. The sequences of HSUR 1 (143 nucleotides), HSUR 2 (115 nucleotides), HSUR 3 (76 nucleotides), and HSUR 4 (106 nucleotides) are related to each other but are distinct from any previously characterized cellular U RNA. The viral genes encoding the HSURs possess conserved enhancer, promoter, and 3' end formation signals unique to U RNA genes. HSUR 1 and HSUR 2 have a similar 5' end sequence that exhibits perfect complementarity to the highly conserved AAUAAA polyadenylation signal. Oligonucleotide directed RNAase H degradation indicates that this 5' end region is available for base pairing interactions within the HSUR 1 and HSUR 2 snRNP particles.

Absence seizure with generalized rhythmic delta activity

In seven children, 5-11 years old, who presented with spells of staring or unresponsiveness, hyperventilation reproduced clinical spells that were accompanied on the EEG by generalized, rhythmic, delta activity. The discharges were usually of abrupt onset, extremely high amplitude, recurrent, and prolonged. One spontaneous staring spell, not provoked by hyperventilation, was also accompanied by generalized rhythmic delta activity. All patients had improvement or complete control of their spells and abolition of the EEG changes with ethosuximide or valproate. Delta activity during hyperventilation in children may not always be benign and may be associated with clinical absence seizures.

Amount of RNA secondary structure required to induce an alternative splice

We set up an alternative splicing system in vitro in which the relative amounts of two spliced RNAs, one containing and the other lacking a particular exon, were directly proportional to the length of an inverted repeat inserted into the flanking introns. We then used the system to measure the effect of intramolecular complementarity on alternative splicing in vivo. We found that an alternative splice was induced in vivo only when the introns contained more than approximately 50 nucleotides of perfect complementarity, that is, only when the secondary structure was much more stable than most if not all possible secondary structures in natural mRNA precursors. We showed further that intron insertions containing long complements to splice sites and a branch point inhibited splicing in vitro but not in vivo. These results raise the possibility that in cells most pre-mRNA secondary structures either are not maintained long enough to influence splicing choices, or never form at all.

The value of nasopharyngeal recording in psychiatric patients

The utility of nasopharyngeal (NP) recording in psychiatry is controversial. To assess its value, 302 NP recordings from patients with psychiatric illnesses were reviewed. Among the 81 patients whose electroencephalograms (EEGs) demonstrated spikes or sharp waves, 10 patients (12%) were found to have epileptic foci at the mesiobasal temporal region recorded exclusively by NP leads. However, all of these recordings showed additional independent epileptic foci detected by scalp electrodes. Five patients (6%) had epileptic discharges simultaneously recorded from NP and scalp electrodes. No recording showed all epileptic discharges to be exclusively recorded by NP leads. These findings suggest that although NP recording may not be absolutely required to determine if an EEG contains epileptiform discharges, in a psychiatric population, it may be useful to detect additional epileptic foci at the mesiobasal temporal region.

Ictal tinnitus

Unilateral high pitched tinnitus was the sole epileptic ictal manifestation of a 45-year-old woman. Electrographic seizures originated from the contralateral midtemporal area and consistently correlated with tinnitus. Computed tomography (CT) demonstrated a lesion involving the superior temporal gyrus and inferior portion of the supramarginal gyrus. The case illustrates a cortical origin of tinnitus.