Panayiotopoulos-type benign childhood occipital epilepsy: a prospective study

OBJECTIVE

To characterize the clinical and EEG features of the syndrome of benign childhood partial seizures with ictal vomiting and EEG occipital spikes (Panayiotopoulos syndrome [PS]).

METHODS

Prospective study of children with normal general and neurologic examinations who had seizures with ictal vomiting and EEG with occipital spikes.

RESULTS

From February 1990 to 1997, the authors found 66 patients with PS and 145 children with benign childhood epilepsy with centrotemporal spikes. Peak age at onset of PS was 5 years. Ictal deviation of the eyes and progression to generalized seizures were common. One-third had partial status epilepticus. During sleep, all had seizures. While awake, one-third also had seizures. Five children with PS had concurrent symptoms of rolandic epilepsy and another five developed rolandic seizures after remission of PS. Prognosis was excellent: one-third had a single seizure, one-half had two to five seizures, and only 4.5% had frequent seizures.

CONCLUSIONS

Panayiotopoulos-type benign childhood occipital epilepsy is less common than benign childhood epilepsy with centrotemporal spikes but is well defined and recognizable by clinical and EEG features.

Achalasia presenting as acute airway obstruction

Achalasia presenting as acute airway obstruction is an uncommon complication. We report the case of an elderly woman with previously undiagnosed achalasia who presented with acute respiratory distress due to megaesophagus. Emergency endotracheal intubation and insertion of a catheter into the esophagus, with continuous aspiration was required. Upon introduction of the esophageal catheter an abruptand audible air decompression occurred, with marked improvement of the clinical picture. Endoscopic injection of botulinum toxin was chosen as the definitive treatment with good clinical result. The pathophysiology of the phenomenon of esophageal blowing in achalasia is unclear, but different hypothetical mechanisms have been suggested. One postulated mechanism is an increase in upper esophageal sphincter (UES) residual pressure or abnormal UES relaxation with swallowing in achalasia patients. We reviewed the UES manometric findings in 50 achalasia patients and compared it with measurement performed in 45 healthy controls. We did not find any abnormalities in UES function in any of our achalasia patients group, or in the case under study. An alternative hypothesis postulates that airway compromise in patients with achalasia results from the loss UES belch reflex (abnormal UES relaxation during esophageal air distension), and in fact, an abnormal UES belch reflex was evidenced in our case.

Drop episodes in Coffin-Lowry syndrome: an unusual type of startle response

We present a patient with a complete Coffin-Lowry syndrome, associated with drop episodes precipitated by sudden auditory stimuli, which provoked in turn, a definite loss of muscle tone in both legs. Electrophysiological studies showed that these episodes are an unusual type of startle response and that they may be associated with Coffin-Lowry syndrome.

[Patient assessment of the long-term benefits of surgery in inflammatory bowel disease]

The objective of surgical treatment in ulcerative colitis (UC) and Crohn's disease (CD) differs. Surgery in UC is more aggressive and potentially curative whereas in CD it is more conservative and palliative.

OBJECTIVE

To assess the opinion of patients with inflammatory bowel disease who underwent surgery in the distant past about the results and timing of surgery.

MATERIAL AND METHODS

A total of 50 surgical patients (36 with CD and 14 with UC) who had undergone an intestinal surgical procedure at least one year before. The clinical characteristics of patients and details of surgery procedures were recorded. Also, a personal interview was conducted. Patients were asked about their current clinical status, surgical consequences and their opinion about the appropriate timing of surgery.

RESULTS

Surgery for UC was total proctocolectomy in 85% of patients and it was on an emergency basis in 43% of them. Surgery for UC was partial intestinal or colonic resection, and it was on an emergency basis in 22% of them. Postsurgical complications were more common in UC than CD patients (50% versus 20%; p < 0.05). In CD surgery, recurrence of disease occurred in 78% of patients within a 2.6 years interval. Among UC and CD patients, 71% and 50%, respectively, reported that their presurgical expectatives had been fulfilled (p = 0.17).

CONCLUSIONS

Surgery for UC is associated with an appreciable rate of complications; however, most patients had their expectatives fulfilled with surgery as long-term symptoms were controlled. As for CD, the patient's satisfaction degree was lower than or UC.

[Cerebrovascular accident as the form of presentation of a pancreatic cystadenocarcinoma: an unusual form of presentation in a rare tumor]

Pancreatic cystadenocarcinoma is an uncommon neoplasm of the pancreas. Mucinous cystadenocarcinoma is the most frequent pancreatic cystadenocarcinoma. Symptoms are often non-specific but abdominal pain and jaundice are common in tumors localized in the head of the pancreas. Thromboembolic manifestations of pancreatic neoplasm have been described but are infrequent. The commonest manifestations are migratory thrombophlebitis, mesenteric venous thrombosis and pulmonary embolism. Cerebral stroke as the first manifestation of pancreatic carcinoma is exceptional. The mechanism by which pancreatic carcinoma induces stroke is unclear, although Trousseau's syndrome, complications of mucinous cancer or blood disorders could play a role. We report the case of a young woman with transient stroke and paraneoplastic thrombocytosis in whom pancreatic cystadenocarcinoma was diagnosed.

[Acquired epileptic aphasia]

OBJECTIVE

To evaluate clinical and EEG features, as well as treatment and progression in fifteen patients with a diagnosis of acquired epileptic aphasia.

PATIENTS AND METHODS

The population comprised nine male and six female patients, whose mean age was 14.5 (r = 8.11-20 years). All were on routine antiepileptic drugs. Inclusion criteria were acute, subacute or chronic aphasia, lacking signs of motor deficit or demonstrable brain lesion, but displaying bilateral spikes or generalized spike-wave discharges. Throughout, sleep and waking EEG, neuroimaging, brainstem auditory evoked potentials and neuro-psychological evaluations were performed. Cortical brainstem auditory evoked potentials were carried out in ten cases.

RESULTS

Median age at onset of verbal auditory agnosia was 5.6 years (r = 1.1-8.6 years), which eleven cases developed epileptic seizures at a median age of five years. Waking and sleep EEG were abnormal but brainstem auditory evoked potentials were normal throughout. Cortical brainstem auditory evoked potentials in ten patients displayed P300 wave and vertex potential alterations. Five cases received 1-3 mg/kg/day prednisone during 6-12 months, with almost complete speech recovery in four. At the last follow-up, language impairment was mild in five patients, moderate in five and severe in three, while two children recovered normal speech.

CONCLUSIONS

Early acquired epileptic aphasia treatment is advisable with valproic acid, benzodiazepines or ethosuximide alone or in combinations, supplementary with corticoids for at least six months in the absence of clinical response and/or EEG improvement. Globally, seven out of fifteen patients overcame their speech disorder.

[Cerebral magnetic resonance in the study of West syndrome]

INTRODUCTION AND OBJECTIVE

West's syndrome (WS) is an epileptic encephalopathy of the first year of life, associated with different aetiologies. MRI of the brain allows precise determination of the type and extent of the lesions. The aetiology must be recognised in order to establish the prognosis and a suitable therapeutic approach. The objective of this study is to analyse the aetiologies of a population of children with WS and compare the results of cases diagnosed before and after using MRI.

PATIENTS AND METHODS

We analyzed the clinical histories of 448 patients fulfilling the diagnostic criteria for WS (infantile spasms and a EEG with a pattern of hypsarrhythmia), 217 in pre-MRI era (group 1) and 231 in the post-MRI era (group 2). The following parameters were analyzed: type of WS, sex, duration of follow-up, age of onset of infantile spasms and particularly the neuroradiological studies.

RESULTS

Group 1: symptomatic WS, 157 patients; cryptogenic WS, 60 patients. Group 2: symptomatic WS, 169 patients; cryptogenic WS, 62 patients. The aetiologies of symptomatic WS were: cortical dysplasias, neurocutaneous disorders, cerebral malformation and prenatal clastic lesions, hypoxic ischaemia, post-infection, metabolic, tumors, Down's syndrome, others and unknown cause.

CONCLUSIONS

It is known that cerebral MRI gives better definition of these types of cerebral lesions than cerebral CT does. We emphasize the importance of MRI in patients with symptomatic WS for precise determination of the aetiology, and speculate as to whether some of the 21 cases of unknown aetiology of group 1 could have been diagnosed if studied nowadays.

Influence of the smoking habit in the surgery of inflammatory bowel disease

The smoking habit is a key factor in the development of inflammatory bowel disease (IBD), but little information exists as to the relationship between smoking habit, the need of surgery and its complications.

OBJECTIVES

To investigate the relationship between smoking habit, the need of surgery, their complications and clinical recurrence after surgery in Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

We studied a group of 62 patients (22 with UC and 40 with CD) with previous surgery. We analyzed the clinical and surgical characteristics of the disease. Smoking habit was established by a personal interview. This group of patients was compared with another control group of 202 patients (133 with UC and 69 with CD) with IBD without previous surgery.

RESULTS

Smoking habit was similar between operated and non-operated patients for both UC (73% and 80% non-smokers) and CD (67% and 63% smokers) The number and type of complications after surgery were not related with smoking habit. In CD patients, although the recurrences did not depend on the smoking habit, they did occur earlier in smokers than in non smokers (83.6 +/- 21 vs 155 +/- 50 weeks, p = ns).

CONCLUSIONS

The smoking habit does not seem to influence significantly the need of surgery and post surgical development of IBD, although in CD the smokers seems to present recurrence before non smokers.

Histone H4 acetylation analyses in patients with polysomy X: implications for the mechanism of X inactivation

In humans, it is thought that the X-inactivation phenomenon occurs no matter how many X chromosomes are present, and that only one of them remains active. Nevertheless, individuals who have an abnormal number of X chromosomes show a wide spectrum of abnormalities, which increase with the number of X chromosomes present in a given individual. It has been shown that the inactive X chromosome in female mammals is distinguished by a lack of histone H4 acetylation, and that this could be used as an accessible marker for distinguishing between Xi and Xa in spreads of metaphase chromosomes. We studied three X-polysomic patients for the presence of active chromatin by analysis of histone H4 acetylation on unfixed metaphase spreads. Using antisera to H4 acetylated at lysines 16, 8 and 5, respectively, we observed frequencies different from those expected from cells with only one underacetylated X chromosome. In particular, when antiserum to H4 acetylated at lysine 16 was used about 90% of the cells showed acetylation of all X chromosomes. This suggests a possible disturbance in the deacetylation process, probably due to the presence of multiple Xs.

[Rasmussen syndrome]

INTRODUCTION

Rasmussen's encephalitis is a neurological disorder probably of immunological origin, characterized by intractable epilepsy, neurological deterioration and the presence of antibodies against R3 glutamate receptors.

OBJECTIVE

To present the experience of an Argentinian Paediatric Neurology Service during the past 7 years.

MATERIAL AND METHODS

We analyzed the clinical histories of 12 patients with RS as defined by the diagnostic criteria proposed by Hart et al. We evaluated the following parameters: neurological examination, neuropsychological assessment, types of crises, age of onset, frequency, distribution, electroencephalogram, video EEG, evoked potentials, neuro-radiological studies; CT and cerebral MR using gadolinium, SPECT, lumbar puncture and cerebral biopsy.

RESULTS

The crises were of simple partial motor type in 12 cases, secondarily generalized partial crises in 7 cases, complex partial crises in 4 cases and partial and generalized motor states in 8 cases. RESULTS. The ictal EEGs during the continuous partial crises showed contralateral focal slow activity of the affected side of the body in 30% of cases. The neuro-radiological studies (CT and MR) showed signs of cerebral hemiatrophy in all 12 cases, hyper-intense images in the T2 sequences of the fronto-temporo-parietal regions in 5 cases, an asymmetric megacisterna magna in 1 case and hypoplasia of the cerebellar vermis in another case.

CONCLUSIONS

The continuous partial crises showed little correlation with the electro-encephalography. Following administration of i.v. gammaglobulin there was a transient halt in progression of the neurological deterioration and control of the crises in 55% of the cases. Surgery continued to be the treatment recommended for control of the epileptic crises.

Psychological and spiritual growth in women living with HIV

Women living with HIV and AIDS face tremendous obstacles to wellness, yet many find ways to use their experience of HIV as a vehicle for psychological and spiritual growth. A qualitative study was conducted to better understand this process. Thirty-four women living with various stages of HIV were interviewed. Five components were found to be important in their psychological and spiritual growth: reckoning with death, life affirmation, creation of meaning, self-affirmation, and redefining relationships. Implications for social work practice and future research are discussed.

[Education of patients with rheumatoid arthritis. Assessment of a survey of interests]

BACKGROUND

The congruence of interests between health care providers and clients is essential if subjects with chronic diseases will be educated.

AIM

To assess, in patients with rheumatoid arthritis, those fields in which they would like to receive education.

PATIENTS AND METHODS

Eighty eight patients with rheumatoid arthritis were surveyed about the topics in which they would like to be educated. The inquiry included medical aspects, handicap overcoming, social issues and labor aspects.

RESULTS

Eighty two percent of patients were interested in medical aspects, 77% in social issues and 71% in handicap overcoming. Eighty three percent of patients with greater handicaps preferred handicap overcoming, 75% social aspects and 74% medical aspects. Younger patients had a greater interest in labor aspects, those with a recently diagnosed disease were interested in their legal rights and those with a prolonged disease wanted information about self help groups.

CONCLUSIONS

The greater educational interests of patients with rheumatoid arthritis were on medical aspects. However, those impaired by the disease were interested in handicap overcoming. Age and duration of the disease also influenced the educational interests of patients. Thus, education in these patients must be individualized.

Effects of smoking on the presentation and clinical course of inflammatory bowel disease

OBJECTIVE

To evaluate the influence of regular smoking on the presentation and clinical course of inflammatory bowel disease.

METHODS

We performed a case-control study interviewing 160 inflammatory bowel disease patients (63 with Crohn's disease (CD) and 97 with ulcerative colitis (UC)) and 140 first-degree relatives as controls. The risk of developing the disease relative to a smoking habit was calculated as the odds ratio. Furthermore, to evaluate the influence of smoking on the subsequent course of inflammatory bowel disease, we performed a multivariate analysis that included pertinent variables such as the need for surgery, number of hospitalizations and relapses.

RESULTS

The pattern of smoking in UC patients was different from that in CD patients. In UC there was a significant predominance of non-smokers and ex-smokers (P = 0.02), whereas smoking habits in CD were not different from those in controls. Giving up smoking was a risk factor to develop UC (odds ratio: 3.2, P = 0.02). In UC, non-smokers and specially ex-smokers need surgery more frequently than smokers (P < 0.01). Otherwise the relapse/year index was not influenced by smoking. In CD there was a non-significant association between smoking habits and the various clinical parameters analysed. UC patients who begin smoking after diagnosis of the disease present a significant reduction in the number of recurrences.

CONCLUSION

Smoking habit significantly affects the presentation and clinical course of UC, whereas in CD, a smoking habit does not have any apparent influence on the disease.

Late complication of laparoscopic salpingoophorectomy: retained foreign body presenting as an acute abdomen

BACKGROUND

Laparoscopy is widely used as a tool in many clinical situations allowing for diagnosis and/or surgical management in a minimally invasive fashion. Most laparoscopic cases are ambulatory and allow patients to recover quickly. Nonetheless, attention to surgical technique is paramount to avoid both short and long term complications.

CASE

A 32-year-old woman had a laparoscopy and a reported left salpingoophorectomy for benign disease of the ovary in September, 1994. Shortly thereafter, in January, 1995, she was diagnosed with an intrauterine pregnancy and delivered in October of 1995 by spontaneous vaginal delivery. The pregnancy and delivery were both uncomplicated. The patient presented four weeks postpartum with clinical suspicion of appendicitis. However, at the time of laparotomy, the patient was found to have a retained foreign body from her prior laparoscopy in the right lower quadrant with a pelvic abscess and evidence of prior right salpingoophorectomy. The appendix appeared grossly normal.

CONCLUSION

Laparoscopy is a safe, effective modality for various surgical and gynecologic conditions. Although laparoscopy is usually done on an outpatient basis, complications can manifest several weeks or months later. This case illustrates and reminds us of the importance of adherence to surgical laparoscopic principles. These include direct visualization when removing equipment and a complete count of surgical instrumentation to confirm the integrity of such at the end of each procedure.

[Juvenile myoclonic epilepsy]

Since juvenile myoclonic epilepsy (EMJ) and/or Janz syndrome is a primary syndrome which persists throughout life, there should be permanent behavioural hygiene and treatment to keep it under control. Suspension of treatment is nearly always followed by recurrence. Although some researchers report relapses of 75% on suspension of treatment, Janz (1995), cited by Dreifuss points out that this rises to 91% in patients who suspend treatment after two years with no crises. This is, to date, the highest documented level of relapses in epilepsy (5,6,12).

Unexpected familial recurrence of iris coloboma. A delayed mutation mechanism?

Typical isolated ocular coloboma is a congenital abnormality caused by a defective closure of the embryonic fissure of the optic cup. Although an irregular autosomal dominant mechanism of inheritance has been proposed, there is some evidence of other modes of transmission and etiologies. This report shows an unexpected recurrence of iris coloboma, occurring in three sibships of the same family, that could be explained by a "delayed mutation" or "premutation" mechanism.

Molecular size-fractionation during endocytosis in macrophages

The sorting of macromolecules within and between membranous organelles is often directed by information contained in protein primary or secondary structure. We show here that absent such structural information, macromolecules internalized by endocytosis in macrophages can be sorted by size. After endocytosis, small solute probes of fluid-phase pinocytosis were recycled to the extracellular medium more efficiently than large solutes. Using macropinosomes pulse labeled with fluorescent dextrans, we examined the ability of organelles to exchange solute contents. Dextran exchange was optimal between organelles of similar age, and small dextrans exchanged more efficiently than large dextrans. Efferent solute movement, from lysosomes or phagolysosomes toward the plasma membrane, occurred through the same endocytic vesicles as afferent movement, toward lysosomes and this movement was solute size dependent. Remarkably, uniform mixtures of different-sized dextrans delivered into lysosomes separated into distinct organelles containing only one dextran or the other. Thus, the dynamics of endosomes and lysosomes were sufficient to segregate macromolecules by size. This intracellular size fractionation could explain how, during antigen presentation, peptides generated by lysosomal proteases recycle selectively from lysosomes to endosomes for association with class II MHC molecules.

Parental origin of the extra chromosomes in polysomy X

Five polymorphic index markers were analyzed by polymerase chain reaction (PCR) to ascertain the parental origin of the extra X chromosomes in seven polysomic cases (one 49,XXXXX, three 49,XXXXY, two 48,XXXY, and one 48,XXYY). All four X chromosomes in 49, X polysomies were maternal in origin and the extra X chromosomes in 48 X polysomies were paternal. In each case the multiple X chromosomes were contributed by a single parent. Taken together with previously reported cases, these data support a single mechanism of sequential nondisjunction during either maternal or paternal gametogenesis as the cause of higher order sex chromosome polysomy.