Ultra-early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke.

BACKGROUND AND PURPOSE: Subclinical atrial fibrillation (AF) is known to underlie a number of cases of cryptogenic stroke (CrS). However, there is need to define the most effective strategy for AF detection. The diagnostic usefulness was analysed of a strategy based on ultra-early continuous monitoring in patients with CrS in terms of AF detection, oral anticoagulation treatment and stroke recurrence, in comparison to a standard outpatient strategy. METHODS: Patients with ischaemic stroke of undetermined origin and confirmed to be cryptogenic after extensive work-up were searched for AF with (i) a conventional strategy (historical cohort, n = 101) with serial electrocardiograms and 24-h Holter monitoring or (ii) an ultra-early monitoring strategy with insertable cardiac monitor (ICM) implanted before discharge (prospective cohort, n = 90). AF episodes lasting >1 min, anticoagulant treatment and stroke recurrence were recorded. RESULTS: During admission, AF was similarly detected in both cohorts (24% of patients). After discharge (mean follow-up 30 ± 10 months), AF detection rates were 17/80 (21.3%) and 38/65 (58.5%) for patients in the conventional versus the ultra-early ICM group (P < 0.001). Up to 41% of AF cases in the ICM cohort were detected within the first month. Oral anticoagulation was initiated in 37.6% versus 65.5% (P < 0.001) and stroke recurrence was recorded in 10.9% versus 3.3% (P 0.04) in the conventional versus the ICM cohort. CONCLUSIONS: Pre-discharge ICM implant allows detection of AF during follow-up in up to 58% of selected patients with CrS. Compared to a conventional strategy, ultra-early ICM implant results in higher anticoagulation rates and a decrease in stroke recurrence.

Reparación perineal transvaginal del rectocele sintomático mediante perineorrafia protésica con malla de marlex. Valoraciones anatomoclínicas, fisiológicas y de tratamiento / Transvaginal perineal repair of symptomatic rectocele using a Marlex mesh prosthesis: anatomoclinical, physiological and treatment considerations/assessment

Introducción. El propósito de este estudio es valorar el tratamiento de los rectoceles sintomáticos, en un grupo seleccionado de pacientes, mediante una técnica diseñada personalmente, en función de su etiología (fallo de la fascia de Denonvilliers), y con la colocación de una malla de Marlex. Pacientes y métodos. Se seleccionaron exclusivamente 12 pacientes en las cuales existía una historia de estreñimiento grave y que, además del uso diario de laxantes, recurrían a la digitación como única solución para la evacuación rectal. Se realizó un abordaje quirúrgico perineal transvaginal, colocándose una malla de Marlex anclada sobre la fascia de Denonvilliers y posteriormente una colpectomía romboidal posterior de la pared redundante. Resultados. Todas las pacientes notaron una mejoría inmediata de los síntomas con una evacuación sin necesidad de digitación, a la vez que desapareció el prolapso vaginal posterior. La rectificación del rectocele fue perfecta y se normalizaron los parámetros anatómicos, fisiológicos y radiológicos. Conclusiones. La perineorrafia protésica transvaginal mejora de forma definitiva los síntomas del rectocele de gran tamaño, tratando a la vez los dos parámetros anatomoclínicos, de distensión rectal anterior y prolapso vaginal posterior (AU)

The alpha 2-adrenoreceptor agonist clonidine suppresses seizures, whereas the alpha 2-adrenoreceptor antagonist idazoxan promotes seizures in amygdala-kindled kittens: a comparison of amygdala and pontine microinfusion effects.

PURPOSE: We sought to determine whether local, in vivo microinfusion of an alpha 2-adrenoreceptor agonist and antagonist into either the amygdala or the pons (locus ceruleus, LC) would have contrasting effects on evoked amygdala-kindled seizure susceptibility. METHODS: The study population consisted of 6 amygdala-kindled kittens, each undergoing the same protocol, in which the amygdala microinfusion paradigm preceded the pontine microinfusion series. Microinfusions (1 microliter) of the alpha 2-agonist clonidine (CLON) and the alpha 2-antagonist idazoxan (IDA) were made over 1 min through cannulas adjacent to stimulating electrodes in the kindled amygdala or through cannulas adjacent to recording electrodes in the ipsilateral LC. Order of administered drugs (CLON vs. IDA) and dosages (n = 3 each) was partly counterbalanced. Focal and convulsive seizure thresholds were evaluated 10-12 min postinfusion and compared to thresholds obtained during two interspersed control conditions (vehicle control = 1 microliter microinfusion of sterile saline; sham control = needle insertion only). RESULTS: CLON significantly increased focal and generalized seizure thresholds, whereas IDA significantly reduced seizure thresholds when compared to controls. Magnitude of effects was dose dependent and more potent after pontine than amygdala microinfusion. CONCLUSIONS: Our results confirm and extent findings of previous researchers who used unlocalized in vivo manipulations to show that norepinephrine (NE) is a highly antiepileptic agent in the amygdala kindling preparation. With further investigation, the results may ultimately lead to development of microinfusion techniques as an alternative treatment option for limbic epilepsy.

The alpha 2 adrenoreceptor agonist clonidine suppresses seizures, whereas the alpha 2 adrenoreceptor antagonist idazoxan promotes seizures: pontine microinfusion studies of amygdala-kindled kittens.

This is the first report showing that microinfusion of alpha 2 adrenoreceptor agonists and antagonists into the vicinity of the locus ceruleus (LC) have contrasting effects on evoked amygdala-kindled seizure susceptibility. Microinfusion (1 microliter) of the alpha 2 agonist clonidine (CLON) and of the alpha 2 antagonist idazoxan (IDA) were made over 1 min through cannulae in the LC ipsilateral to the kindled amygdala in 6 kittens. Order of administered drugs (CLON vs. IDA) and dosages (n = 3 each) were partly counterbalanced. Focal and convulsive seizure thresholds were evaluated 10-12 min post-infusion and compared to thresholds obtained during two, interspersed control conditions (vehicle control = 1 microliter microinfusion of sterile saline; sham control = needle insertion only). CLON significantly elevated focal and generalized seizure thresholds, whereas IDA significantly reduced seizure thresholds when compared to controls. Magnitude of effects was dose-dependent. These findings confirm that norepinephrine (NE) is a potent antiepileptic agent. Results also suggest that pontine microinfusions could eventually provide an alternative treatment option for medically refractory limbic epilepsy.

Paroxysmal microarousals in amygdala-kindled kittens: could they be subclinical seizures?

Amygdala-kindled kittens exhibit frequent epileptiform EEG transients, often in conjunction with phasic arousal events of sleep [k-complexes, pontogeniculo-occipital (PGO) waves, and/or sleep spindles]. In this study, paroxysmal microarousals occurred throughout the sleep-wake cycle after kindling, but were most frequent during seizure-prone states of slow-wave sleep (SWS) and the transition into rapid-eye-movement sleep (REM). Their incidence correlated with interictal sleep fragmentation as well as onset of spontaneous convulsions. Results could reflect transsynaptic kindling effects on brainstem and forebrain arousal mechanisms with which amygdala is reciprocally connected. Increased discharge rates of neural generators for normal EEG and behavioral arousal could disrupt sleep at some times and recruit epileptic neurons in the kindled focus to precipitate seizures at others. Alternatively, epileptiform EEG paroxysms were accompanied by subtle behavioral stereotypes (a head nod, limb elevation, eye twitch, lip smack, or a combination of these). Behavioral correlates were elements of partial kindled seizures, suggesting that paroxysmal microarousals may be subclinical seizures. Whether or not the microarousals are true seizures, our findings may link ictal onset and interictal sleep disorders to a subclinical paroxysmal arousal disorder and suggest a common epileptic mechanism.

Ontogeny of feline temporal lobe epilepsy. III: Spontaneous sleep and arousal disorders in amygdala-kindled kittens.

We report the ontogeny and persistence of sleep and arousal disorders in amygdala-kindled kittens. We also identify procedural differences that may explain discrepancies in the literature on postkindling sleep disorders. The study population consisted of 12 preadolescent kittens kindled between 2.5 and 6.5 months of age, 8 of which were followed to adulthood (> or = 1 year), and 8 unkindled implanted control animals. Sleep and seizure patterns were monitored on 12-24-h polygraphic or split-screen video recordings of EEG and behavioral activity. Kindled kittens displayed spontaneous seizure and interictal sleep anomalies that persisted to adulthood, as follows. As compared with neurosurgical controls, kindled kittens exhibited slow-wave sleep (SWS) and REM sleep insomnia at least 1 year after kindling and 1-5 months after convulsions, regardless of postictal recording delay. Sleep and arousal defects in kindled kittens were similar to but more pronounced than those in kindled adult cats, possibly because kittens spontaneously became epileptic. Detection of postkindling SWS insomnia could be masked by brief scoring epochs (less than the preferred 1-min epoch for cats); recurrent behavioral arousals after kindling frequently aborted 1-min SWS epochs but often did not interrupt 30-s SWS epochs (based on 1-min vs. 30-s minimum duration scoring criteria). Detection of postkindling REM sleep insomnia could be masked in kittens with alternating patterns of REM loss and REM rebound; all these kittens showed periodic bouts of REM onset from waking after kindling. Different data collection and analysis procedures influence detection of sleep and arousal disorders in amygdala-kindled cats when replication of findings is attempted. We conclude that these differences explain some controversies regarding the nature and prevalence of sleep disturbances in the kindling literature in temporal lobe epilepsy (TLE).

The alpha 2-agonist clonidine suppresses seizures, whereas the alpha 2-antagonist idazoxan promotes seizures--a microinfusion study in amygdala-kindled kittens.

This is the first report showing that local, in vivo microinfusion of alpha 2-adrenoreceptor agonists and antagonists have contrasting effects on amygdala-kindled seizure susceptibility. Microinfusions (1 microliter) of the alpha 2-agonist clonidine (CLON) and of the alpha 2-antagonist idazoxan (IDA) were made over 1 min through cannulae adjacent to stimulating electrodes in five amygdala-kindled kittens. Order of administered drugs (CLON vs. IDA) and dosages (n = 3 each) was partly counterbalanced. Focal and convulsive seizure thresholds were evaluated 10-12 min post-infusion and compared to thresholds obtained during two, interspersed control conditions (vehicle control: 1 microliter microinfusion of sterile saline; sham control: needle insertion only). CLON significantly elevated focal and generalized seizure thresholds, whereas IDA significantly reduced seizure thresholds when compared to controls. Magnitude of effects was dose-dependent. Results confirm and extend previous findings which employed unlocalized, in vivo manipulations to show that norepinephrine is a potent antiepileptic agent in the amygdala kindling preparation.

Prevalence rate of hypertension among recent Southeast Asian refugees to northern California.

BACKGROUND: Little is known regarding the prevalence rate of hypertension among recent Southeast Asian refugees to the United States. METHODS: In this randomized, prospective study, four northern California counties with large Southeast Asian refugee populations were screened for the prevalence rates of hypertension and borderline hypertension. A population density method based upon 1988 census data was used to screen a representative sample of subjects from each county. Criteria for hypertension came from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. RESULTS: In all, 964 subjects were screened. We found a prevalence rate of 4.8 percent for hypertension and 10.9 percent for borderline hypertension. CONCLUSIONS: The relatively low prevalence rates of this disease can be explained by the youth of this refugee population, mean age 37.6 +/- 0.36 years, as the presence of hypertension increases with chronological age.