Successfully Treated Psychogenic Non-Epileptic Seizure with Shigyakusan and Hangebyakujutsutemmato / 日本東洋医学雑誌

We report a case of loss of consciousness multiple times with and without focal to bilateral tonic-clonic seizure-like episodes that we diagnosed as psychogenic non-epileptic seizures, and successfully treated with shigyakusan and hangebyakujutsutemmato. The patient did not have fullness and discomfort in the chest and hypochondrium (kyokyokuman), nor spasmodic bilateral rectus abdominis in an interictal state. On the other hand, she had extremely cold limbs, especially feet and hands, with fingers being flexion and rigid under the status of loss of consciousness even without tonic-clonic seizure-like episodes in the ictal state. After being warmed and loosened, her consciousness level slowly recovered. She had headaches frequently in a non-ictal state, too. We identified that she had qi deficiency (kikyo), qi depression (kiutsu), fluid retention (suitai) and qi counter flow (kigyaku) in the interictal state, while kiutsu and kigyaku were extremely strong in the ictal state. In this case, the combined use of shigyakusan and hangebyakujutsutemmato was useful, considering that the patient had two different locations of disease (byoi) that required treatment.

Clinical Features of Multicenter Autoimmune Glial Fibrillary Acidic Protein Astrocytosis / 罕见病研究

  Objective  To investigate the clinical features of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy.  Methods  We collected and analyzed the clinical and laboratory data and obtained the clinical characteristics of diagnosis and treatment from fifteen patients with positive GFAP antibody tested by cerebrospinal fluid and diagnosed autoimmune GFAP astrocytopathy by the multi-centers.  Results  The mean age of the first onset of autoimmune GFAP astrocytopathy was 39.73 years old (range 4-65 years), with no significant gender difference. In terms of clinical manifestations, we found the whole brain symptoms including abnormal mental behavior, disturbance of consciousness, epileptic attack accounting for more than 50, , meningitis accounting for 66.7%, myelitis (53.3%), limb tremor (53.3%), vision loss (33.3%); systemic symptoms including fever(100%) and fatigue(86.7%). 46.7% of patients were initially diagnosed with tuberculous meningoencephalitis and were treated with diagnostic antituberculous therapy. The MRI showed 46.7% of patients showed brain linear perivascular radial gadolinium enhancement in the white matter perpendicular to the ventricle.  Conclusions  Autoimmune GFAP astrocytopathy are acute or subacute dieases and the main clinical features include encephalitis, meningitis, myelitis and optic neuritis. They are likely to be misdiagnosed as tuberculous meningoencephalitis and can manifest progressive loss of consciousness in early phase, which is even life threatening.

Comparison of induction and recovery characteristics of Propofol and Sevoflurane in daycare adult tonsillectomies

Background: Type2 diabetes mellitus (T2DM) is a highly inheritable disease. Transcription factor 7- like 2 (TCF7L2) gene regulates the expression of glucagon-like peptide 1 (GLP-1) in L cells of small intestine. GLP1 plays a critical role in blood glucose homeostasis by stimulating postprandial insulin secretion and increasing insulin sensitivity. Aim of the study: TCF7L2 gene variants may affect the susceptibility to Type 2 diabetes by altering GLP-1 levels. Materials and methods: This case-control study was conducted with 90 newly diagnosed patients with Type2 diabetes mellitus as cases and 90 age and sex-matched healthy volunteers as controls. TCF7L2 rs7903146 genotyping was done and we also estimated Fasting and postprandial GLP -1 level, Fasting and Postprandial insulin level and calculated HOMA-IR in both cases and controls. Results: Out study showed that T+ genotype, lower fasting GLP-1 level and lower postprandial GLP1 levels were more observed among cases as compared to controls. Low mean GLP 1 activity, high Mean HOMA-IR, low postprandial insulin, low percentage rise in insulin were observed among T+ genotype than among T- genotypic individuals. Conclusion: Hence, the study concludes that T+ genotype causes a decrease in GLP-1 levels, which in turn by decreasing postprandial insulin levels and by increasing insulin resistance increases the risk of Type2 diabetes.

Relationship between maintaining concentration and loss of consciousness concentration of propofol target controlled infusion in patients undergoing heart valve replacement / 临床麻醉学杂志

Objective To investigate the relationship between maintaining concentration and loss of consciousness (LOC) concentration of propofol target controlled infusion (TCI) in patients undergoing heart valve replacement.Methods Thirty patients undergoing elective heart valve replacement were enrolled to receive propofol by ladder plasma TCI for anesthesia induction,8 males and 22 females.The initial plasma concentration (Cp) of propofol was set to 1.0 μg/ml,0.3 μg/ml Cp was increased every 1 min until LOC when the prediction effect-cite concentration (Ce) reached 0.5 μg/ml,then sufentanil 0.8-1.0 μg/kg and rocuronium 0.6-0.9 mg/kg were given for intubation.When BIS reached 50,Cp was decreased to the level of Ce.All the surgeries were performed under hypothermia CPB.MAP,HR,CVP,CO,SV,SVR,BIS,propofol Cp and Ce values were recorded at baseline (T0),LOC (T1),BIS reached 50 (T2),and other time points during operation (T3-T9).The correlation analysis between propofol Ce at LOC and perioperative variables were completed.Results In correlation analysis,there was a significant positive correlation between propofol Ce at LOC and baseline CO,SV (P<0.01),there was a significant negative correlation between propofol Ce at LOC and age (P<0.05),there was a significant positive correlation between propofol Ce at LOC and propofol Ce at T2-T9(P<0.01).Conclusion In patients undergoing valvular replacement,the Ce of propofol at maintenance are related to the concentration of propofol at LOC,which is helpful for adjusting the Ce of propofol at maintenance according to the Ce of propofol at LOC.

Effects of target-controlled infusion of dexmedetomidine on the median effective concentration of effect-site of propofol at loss of consciousness / 临床麻醉学杂志

Objective To investigate the effects of target-controlled infusion (TCI)of dexme-detomidine on the median effective concentration of effect-site (Ce50 )of propofol at loss of conscious-ness (LOC)in patients.Methods Sixty-four patients,28 males and 36 females,aged 20-60 years, ASA physical status Ⅰ or Ⅱ,scheduled for elective surgery,were randomly allocated to receive dexmedetomidine of 0 ng/ml (group P),dexmedetomidine of 0.4 ng/ml (group D1),dexmedetomi-dine of 0.6 ng/ml (group D2)and dexmedetomidine of 0.8 ng/ml (group D3)for 1 5 min before TCI of propofol,n =1 6 in each group.The propofol infusion was started to provide an effect-site concen-tration of 1.0 μg/ml,and increased by 0.2 μg/ml when propofol effect-site concentration and target concentration were equilibrium until LOC.Results The Ce50 (95%CI )at loss of consciousness in groups P,D1,D2 and D3 were 2.30 (2.24-2.36)μg/ml,1.92 (1.87-1.96 )μg/ml,1.60 (1.55-1.65)μg/ml and 1.41 (1.35-1.45 )μg/ml,respectively.There was a negative correlation between the effect-site concentration of propofol-induced LOC and target concentration of dexmedetomidine (r=-0.84,P <0.01).Compared with groups P,D1 and D2,the incidence of bradycardia was higher in group D3 (P <0.05).Conclusion The Ce50 of propofol-induced LOC gradually decreases with in-creasing target concentration of dexmedetomidine.Combining propofol with dexmedetomidine of 0.4 or 0.6 ng/ml that can reduce the Ce50 of propofol-induced LOC,which is suitable for induction of an-esthesia with a lower incidence of bradycardia.

The clinical features and identification of autonomic nervous mediated syncope and pseudo psychogenic syncope in children / 临床儿科杂志

Objectives To analyze and compare the clinical features of autonomic nervous mediated syncope (NMS) and pseudo psychogenic syncope (PPS) in children.Methods Clinical features were retrospectively analyzed in children with syncope complaint not caused by cardiac syncope, situation of syncope, drug-induced syncope, and neurogenic and metabolic diseases that caused brief loss of consciousness, and the clinical features of similarities and differences between NMS and PPS were compared. Results In 106 children with syncope were included, there were 85 cases (80.2%) of NMS, 13 cases (12.3%) of PPS, and 8 cases (7.5%) of unexplained syncope. PPS was induced by recent mental stimulation; the syncope was more frequent; the score of orthostatic intolerance was higher; the omen was rare; the duration of attack was longer. NMS was induced by long time standing, movement and body position change; the omen was mainly dizziness, blurred vision and gastrointestinal symptoms; the duration of attack was short (<5 min).Conclusions NMS is the most common cause of syncope in children, while PPS is an important cause of transient consciousness of non-syncope. There are similarities in clinical features between NMA and PPA and differential diagnosis is needed.

Accidente isquémico transitorio de causa hemodinámica / Transient ischemic attack of hemodynamic cause

El síncope es una perdida súbita y transitoria del estado de conciencia y el tono postural con restitución completa. Según su etiología se clasifica como reflejo (neuromediado), cardíaco, neurológico (isquemia vertebrobasilar) o indeterminado. Los síncopes neurológicos se observan en contexto de accidente cerebrovascular isquémico o accidente isquémico transitorio; frecuentemente se asocian a signos deficitarios focales. Presentamos el caso de un síncope no neurológico con signos deficitarios focales en una paciente con marcada enfermedad ateromatosa. (AU)

Syncope is the abrupt and transient loss of consciousness associated with absence of postural tone, followed by complete and usually rapid spontaneous recovery. In terms of etiology, syncope is classified as reflex (neurally mediated), cardiac, neurologic (vertebrobasilar ischemia) or indeterminate. The neurologic syncope occurs in the setting of stroke or transient ischemic attack, being most frequently associated with focal neurologic symptoms. We report a case of non-neurologic syncope followed with focal neurologic symptoms in a patient with atherosclerosis disease. (AU)

NMDA receptors in central medial thalamus participate in propofol-induced unconsciousness / 天津医药

Objective To investigate the role of NMDA receptors in central medial thalamus (CMT) in the unconscious?ness induced by general anesthesia. Methods A total of 60 rat models for microinfusion were assigned into 4 groups (n=15 for each group). After induction with propofol, 10 mmol/L (NMDA10 group), 20 mmol/L (NMDA 20 group) and 40 mmol/L (NMDA40 group) of NMDA and normal saline (group C) with equal volume were microinfused into CMT. The incidence of purposeful movement and recovery time of righting reflex were observed in each group respectively. Infusion sites were local?ized by histological method. Results When the microinfusion site localized within CMT, comparing with group C, the recov?ery time of righting reflex reduced notably in three NMDA groups (P0.05). Conclusion Microinfusion of NMDA agonist into CMT reverses propofol anesthesia, indicating that NMDA receptor in CMT may contribute to the propofol-induced unconsciousness.

Syncope vs Epilepsy; Neurodiagnostic Evaluations for Differential Diagnosis

PURPOSE: The differential diagnosis between seizure and syncope in a child who visits pediatric neurology clinic with the history of loss of consciousness (LOC), is always challenging issues to the pediatricians. We tried to identify the clinical and laboratory differences between epilepsy and syncope and evaluate the usefulness of EEG and head-up tilt test. METHODS: We retrospectively reviewed the medical records of children who visited pediatric neurology clinic in Asan Medical Center with history of LOC from 2007 to 2011. Patients were divided into three groups, as syncope, epilepsy and syncope with epilepsy, by the diagnosis at the last follow-up. The initial clinical presentations and laboratory findings of each group were evaluated. RESULTS: A total of 145 children were reviewed, but 84 children out of them were included (45 boys, mean age; 13.2 years). Seventy of 84 children (83%) were diagnosed as syncope, 8 (10%) syncope with epilepsy, 6 (7%) epilepsy. Among the syncope groups, neurocardiogenic syncope was the most common, 67(95.7%). The ictal phenomenon such as aura, eyeball deviation, cyanosis and urination were significantly higher in epilepsy patients (P<0.001). The abnormal EEG findings were more likely to be in the epilepsy group, but the sensitivity and specificity was 57%, 90%, respectively. The sensitivity and specificity of head-up tilt tests for syncope were 79% and 100%. Recurrence during follow-up periods were more frequent in epilepsy group (1.2+/-3.8 vs 10+/-10.3, P<0.001). CONCLUSION: Appropriate assessment from history and laboratory data may lead to the proper diagnosis and management in children with LOC, and the careful follow-up and reevaluations are essential to prevent recurrence of LOC.

The spectrum of underlying diseases in children with transient loss of consciousness / 中国小儿急救医学

Objective To analyze the spectrum of underlying diseases in children with transient loss of consciousness (TLOC) through a multi-center and large sample clinical research.Methods Nine hundred and thirty-seven children with TLOC who came from Beijing,Hunan province,Hubei province and Shanghai of China from Aug 1999 to Apr 2011 were recruited in the present study,and then the spectrum of underlying diseases in children with TLOC was analyzed.Results In 937 children with TLOC,903 cases (96.4％ )were children with syncope,34 cases (3.6％) were non-syncope.And in 903 children with syncope,213 cases (23.6％) had vasovagal syncope (VVS) with vasoinhibitory response,46 cases (5.1％ ) had VVS with cardioinhibitory response,112 cases ( 12.4％ ) had VVS with mixed response,268 cases (29.7％ ) had postural tachycardia syndrome,22 cases (2.4％) had orthostatic hypotension,19 cases (2.1％ ) had situational syncope,21 cases (2.3％ ) had cardiogenic syncope,and 202 cases (22.4％ ) had unexplained syncope.Conclusion In children with TLOC,syncope was the most common underlying disease.And in children with syncope,the most common was VVS,followed by postural tachycardia syndrome.In three different hemodynamic patterns of VVS,the most common pattern was VVS vasoinhibitory pattern.

The effect of music on the effect-site concentration of propofol for loss of consciousness / 대한마취과학회지

BACKGROUND: Music reduces anxiety and the need for sedatives in preoperative patients. Currently, propofol is usually infused using target controlled infusion device. With the use of such a device, we investigated the effects of music on the effect-site concentration of propofol for loss of consciousness. METHODS: Sixty-five ASA 1 or 2 patients aged 35 to 55 years who were scheduled for general anesthesia were randomly allocated to either the control, music or headphone group. The control group patients were exposed to the ambient operating room atmosphere (n = 17), the music group patients listened to music (n = 25), and headphone group wore a headphone alone without listening to music (n = 23). Propofol was infused with a predetermined effect-site concentration and we determined loss of consciousness in patients by a verbal response and eyelash reflex for 3 minutes. Each concentration of propofol was predetermined by the up-and-down method with 0.4microgram/ml as the step size. RESULTS: Loss of consciousness was observed at a concentration of 4.20 +/- 0.25microgram/ml in the control group, 3.60 +/- 0.34microgram/ml in the music group, and 3.73 +/- 0.47microgram/ml in the headphone group. The effect-site concentration for loss of consciousness was significantly lower in the music group as compared to the control group (P < 0.05). The effect-site concentration in the headphone group, however, showed no statistical difference as compared to the control group (P = 0.117). CONCLUSIONS: Listening to music reduced overall propofol effect-site concentration for loss of consciousness that was required by patients.

Trastorno por estrés postraumático (TEPT) en pacientes con traumatismo encéfalo craneano (TEC) / Post-traumatic stress disorder in patients following traumatic brain injury

Introduction: Controversy exists as to whether post-traumatic stress disorder (PTSD) may occur after traumatic brain injury (TBI). Objective: To describe the clinical presentation and course of a group of patients that developed PTSD following a work-related TBI. Methods: Clinical records of patients with PTSD treated in Hospital del Trabajador between years 1987 and 2001 were examined. Those cases in which a TBI had occurred were selected and compared with those in which a TBI had not preceded the PTSD. Results: 32 patients were identified as suffering PTSD preceded by TBI. All patients had suffered mild TBI; 62.5% of them as a result of a traffic accident. On average, patients were referred for mental health consultation 70 days after TBI had occurred, and 31.2% of them received specialized treatment for less than three months. When discharged 25% were asymptomatic. When compared with 453 patients suffering PTSD, with no history of previous TBI, treated during the same period, those who had suffered TBI presented a greater proportion of physical lesions, more prolonged treatment periods, and a greater proportion of them were still symptomatic when discharged. Discussion: In a group of patients suffering PTSD, history of mild TBI was a factor associated with a worse prognosis.

Se ha discutido la aparición del TEPT en pacientes que han presentado un TEC. Aunque algunos autores señalan que ambos diagnósticos no pueden coexistir (ya que la amnesia post TEC impediría el procesamiento de la experiencia traumática), otros refieren que no existen diferencias en cuanto a la frecuencia y clínica del diagnóstico de TEPT al comparar pacientes con y sin TEC. Objetivos: Describir las características clínicas y terapéuticas en un grupo de pacientes accidentados del trabajo que han presentado un TEPT después de un TEC. Método: Se revisaron las fichas clínicas de todos los pacientes con diagnóstico de TEPT entre los años 1987 y 2001, se seleccionaron aquéllas en que el TEPT fue posterior a un TEC y se recolectaron las variables en estudio. Además se compararon los resultados con la población de pacientes con TEPT que no había presentado TEC. Resultados: La muestra estuvo constituida por 32 pacientes con TEC leve (62,5% posterior a un accidente de tránsito). Los pacientes fueron derivados a Salud Mental en promedio a los 70 días del accidente; el tratamiento duró 3 meses o menos en el 31,2% de ellos y sólo el 25% estuvo asintomático al momento del alta. En comparación con un grupo de 453 pacientes con TEPT de diverso origen, los pacientes con TEPT y TEC se caracterizaron por haber sido derivados más tardíamente a salud mental, haber sufrido más accidentes de tránsito, haber presentado más lesiones físicas asociadas y haber requerido un tratamiento más prolongado. Conclusiones: En esta muestra de pacientes con TEPT y TEC este último diagnóstico constituyó un factor de peor pronóstico en la evolución del TEPT.

Changes of Tolerance and Cardiovascular Responses to Head-up Tilte Combined with LBNP Following Preceding Exposure to Head-down Tilt / 航天医学与医学工程

Objective To observe pre-syncopal limited tolerance and cardiovascular responses to head-up tilt combined with lower body negative pressure (HUT/LBNP) following exposure to head-down tilt (HDT, -1 Gz). Method Exposures to HUT/LBNP (-60 mmHg) in control session (without preceding 30 s -1 Gz treatment) and in simulated push-pull effect (PPE) session (with preceding 30 s -1 Gz treatment) were performed in 8 healthy adults. The changes of hemodynamic parameters were monitored by electrical impedance instrument during the experiments. Result The mean endurance time in presyncopal symptom limited HUT/LBNP in control session and in simulated PPE session were 8.4±2.1 min and 4.5±2.4 min, respectively, the two means were significantly different (P< 0.01). In simulated PPE session, as compared with baseline, heart rate (HR) during HDT was significantly lowered (P<0.01), while stroke volume (SV) and cardiac output (CO) were increased significantly (P<0.01). During HUT/LBNP, the increased percentage (relative to baseline) of HR in PPE session was lower than these in control session (P<0.05); the decreased percentages of SV and CO during HUT/LBNP in PPE session were both higher than those in control session (P<0.05). During HUT/LBNP, arterial pulse pressure (PP) of control session was significantly decreased than the value of baseline value (P<0.05); Total peripheral resistance (TPR) of PPE session was significantly increased than baseline value (P<0.05). Conclusion Tolerance time before the appearance of presyncopal symptoms during HUT/LBNP decreases and cardiovascular responses to HUT/LBNP are impaired, preceding exposure to HDT.

The Effect of Remifentanil on the Loss of Consciousness during Propofol Infusion / 대한마취과학회지

BACKGROUND: General anesthesia is a balance between hypnosis and analgesia. Remifentanil is often combined with propofol to both induce and maintain total intravenous anesthesia. This study evaluated the effect of remifentanil on the propofol requirements for a loss of consciousness. METHODS: Forty adult patients with ASA 1 or 2 were enrolled in this study. The patients were randomly given either saline or remifentanil before the induction of anesthesia with an infusion of propofol, 15 mg/kg/h. In the remifentanil group, all the patients received a computer controlled infusion of remifentanil with a effect site concentration of 4 ng/ml. The times required for the patient to lose consciousness, the propofol requirements and the bispectral index at the loss of consciousness to verbal commands were recorded. RESULTS: In the remifentanil group, loss of consciousness was attained significantly faster and with lower propofol doses than in the saline group. The bispectral indices were significantly higher at loss of consciousness in the remifentanil group. CONCLUSIONS: A remifentanil infusion before the induction of propofol anesthesia significantly reduces the propofol requirements for the loss of consciousness. Remifentanil enhances the hypnotic effect of propofol.

Neuro-Ophthalmic Manifestations of Head Trauma and Predictive Factors

PURPOSE: To describe the neuro-ophthalmic findings in a group of patients with head trauma. METHODS: A retrospective chart review of all patients who were given a diagnosis code of cerebral concussion and cerebral contusion in a hospital between 1995 and 2003. A total of 1284 consecutive patients were reviewed (972 [76%] men and 312 [24%] women). The mean age was 40.36 years. Motor vehicle accident was the most common cause of head trauma, occurring in 944 (74%) patients. RESULTS: Ophthalmological examination was undertaken in 308 (24%) head trauma patients and an abnormal neuro-ophthalmic examination result was noted in 122 patients (9.5% of total patients, 40% of ophthalmologically examined patients). Traumatic optic neuropathy was the most common manifestation, followed by oculomotor, abducens, trochlear, facial nerve palsy, Terson syndrome and internuclear ophthalmoplegia. Loss of consciousness and cerebral concussion were not associated with any outcomes, but the presence of neuroimaging (computed tomography, magnetic resonance imaging) abnormality, particularly intracranial hemorrhage and skull fracture, was significantly associated with neuro-ophthalmic deficits. CONCLUSIONS: Head trauma causes a number of neuro-ophthalmic manifestations. Intracranial hemorrhage and skull fracture may be a reliable predictor of specific neuro-ophthalmic outcomes.

Posttraumatic Stress Disorder Prevalence, Symptoms, Depressed Mood and Anxiety According to the Presence of Consciousness at the Time of Traumatic Accident / 신경정신의학

OBJECTIVES: This study investigated PTSD prevalence, symptoms, depressed mood and anxiety, comparing two groups of the patients in trauma; one who had experienced the loss of consciousness (group "A" here after) and the other group of patients who had not(group "B" here after). METHOD: Subjects were 120 patients(age18-66) who had received trauma(traffic accident, fall down) more than 1 month. Before they consisted of 56 patients who had experienced the loss of the consciousness(46.7%) and 64 who had not(53.3%). Men were 69 and women were 51. Clinician administered PTSD Scale, Beck Depression Inventory, State Trait Anxiety Inventory-I, II were administered. The factors such as sociodemographic variables, unconsciousness at the time of trauma, memory about traumatic accidents were considered. RESULT: Out of 120 subjects, 30 patients(25%) were diagnosed as PTSD: 17 from 56(30.4%) and 13 from 64(20.3%) were found in the group "A" and "B" respectively. Prevalence of PTSD was higher in the group "A". However, there was no significant difference between two groups(X2=1.607, p>0.05). The CAPS of group "A" showed significantly high frequency in the loss of interest, detachment, restricted affect, sleep difficulty, irritability/anger, concentration difficulty(p<0.05), while the group "B" scored high in intrusive recall and increased startle. The scores of BDI, STAI-I, II were significantly higher in the group "A"(t=-3.16, p<0.05)(t=-2.75, p<0.05, t=-3.38, p<0.05). CONCLUSION: PTSD was more frequent and depressed mood and anxiety appeared more often in the group who experienced the loss of consciousness. Thus the loss of the consciousness at the time of trauma prones of the aevelopment PTSD and to symptom of aepression and anxiety.