Clinical risk factors for non-convulsive status epilepticus during emergent electroencephalogram.

PURPOSE: Emergent electroencephalograms (EmEEG) are performed to exclude non-convulsive status epilepticus (NCSE) but are resource-intensive. Prior studies have identified a seizure or seizures in the acute setting preceding the EmEEG request as a risk factor of NCSE but few other consistent clinical risk factors have been identified. We aimed to identify clinical risk factors for NCSE in EmEEGs METHODS: We conducted a retrospective analysis of consecutive patients who underwent EmEEG to exclude NCSE over a 20-month period. One blinded investigator extracted clinical information from patient case records using a standardized form. Patients were grouped using EmEEG results into those with and without NCSE. We analyzed differences between these two groups. RESULTS: A total of 2333 EEGs were performed over the study period, 215 (9.3%) were EmEEGs ordered to exclude NCSE. 21 patients (9.8%) of the 215 patients were found to have NCSE. Three independent clinical risk factors for NCSE were identified--seizure(s) in the acute setting, ocular movements (nystagmus and/or gaze deviation) and ongoing CNS infection. The presence of seizure(s) in the acute setting showed the highest adjusted odds ratio (OR=8.8, 95% CI 2.0-39.4, p=0.005). In addition, prevalence of NCSE increased as more clinical risk factors were present. CONCLUSION: Seizures in the acute setting, ocular movements and ongoing CNS infection are associated with NCSE. By using these risk factors at the bedside, clinicians can prioritize patients for EmEEG, recognizing that risk of NCSE increases as more clinical risk factors are present.

Successful treatment of macrophage activation syndrome complicating adult Still disease with anakinra.

A previously healthy 20-year-old man presented with adult Still disease (ASD). He developed life-threatening macrophage activation syndrome (MAS), which was refractory to standard immunosuppression but responded dramatically to the IL-1 receptor antagonist anakinra. Subsequent immunological investigations included assessment of the perforin expression of natural killer (NK) cells and CD8+ T cells, which confirmed MAS.

SPECT ventilation perfusion scanning with the addition of low-dose CT for the investigation of suspected pulmonary embolism.

Single-photon emission computed tomography (SPECT) ventilation perfusion (V/Q) scanning with low-dose computed tomography (LDCT) is an emerging imaging technique for investigation of suspected pulmonary embolism (PE). We aimed to estimate diagnostic utility of the combined technique using results from all patients referred in 2009 compared with final diagnosis and 6-month follow-up status. PE was diagnosed in 28 of 106 patients (26%), including in 2 of 80 (2%) with negative SPECT V/Q and LDCT. The estimated negative predictive value of SPECT V/Q for PE was 97%. LDCT was abnormal in 43 (41%) patients, including 41 patients who had negative SPECT V/Q. In 29 (27%) patients, LDCT provided information on alternative pathologies that accounted for presenting symptoms, and the combined technique had a diagnostic yield of 52%.

The regrowth of axons within tissue defects in the CNS is promoted by implanted hydrogel matrices that contain BDNF and CNTF producing fibroblasts.

In this study we demonstrate the potential for combining biocompatible polymers with genetically engineered cells to elicit axon regrowth across tissue defects in the injured CNS. Eighteen- to 21-day-old rats received implants of poly N-(2-hydroxypropyl)-methacrylamide (HPMA) hydrogels containing RGD peptide sequences that had been infiltrated with control (untransfected) fibroblasts (n = 8), fibroblasts engineered to express brain-derived neurotrophic factor (BDNF) (n = 5), ciliary neurotrophic factor (CNTF) (n = 5), or a mixture of BDNF and CNTF expressing fibroblasts (n = 11). Fibroblasts were prelabeled with Hoechst 33342. Cell/polymer constructs were inserted into cavities made in the left optic tract, between thalamus and superior colliculus. After 4-8 weeks, retinal projections were analyzed by injecting right eyes with cholera toxin (B-subunit). Rats were perfused 24 h later and sections were immunoreacted to visualize retinal axons, other axons (RT97 antibody), host astrocytes and macrophages, donor fibroblasts, and extracellular matrix molecules. The volume fraction (VF) of each gel that was occupied by RT97(+) axons was quantified. RT-PCR confirmed expression of the transgenes prior to, and 5 weeks after, transplantation. Compared to control rats (mean VF = 0.02 +/- 0.01% SEM) there was increased ingrowth of RT97(+) axons into implants in CNTF (mean VF = 0.33 +/- 0.19%) and BDNF (mean VF = 0.62 +/-0.19%) groups. Axon growth into hydrogels in the mixed BDNF/CNTF group (mean VF = 3.58 +/- 0.92%) was significantly greater (P < 0.05) than in the BDNF or CNTF fibroblast groups. Retinal axons exhibited a complex branching pattern within gels containing BDNF or BDNF/CNTF fibroblasts; however, they regrew the greatest distances within implants containing both BDNF and CNTF expressing cells.

Do patients with obstructive sleep apnea wake up with headaches?

BACKGROUND: There is a controversy regarding the association of obstructive sleep apnea (OSA) and morning headaches. This study investigates whether this relationship exists. METHODS: This is a retrospective study of 80 consecutive patients with OSA who underwent sleep polysomnography from December 1996 to March 1997. Patients were interviewed about their headache history. Headaches were classified according to International Headache Society criteria and the severity graded by the Chronic Pain Index. Headache characteristics were compared with those of 22 control patients with periodic limb movement disorder. Headache response to continuous positive airway pressure or uvulopalatopharyngoplasty in the patients with OSA was also assessed. RESULTS: Forty-eight (60%) patients had headaches in the year prior to study. Twenty-five of the 48 patients had headaches that did not fit any category. Of these 25 patients, 23 (48% of total group) reported awakening headaches. These awakening headaches were significantly more common in the OSA group compared with the periodic limb movement disorder group, 9 (41%) of whom had headaches, none of which occurred on awakening. The proportion of common types of headaches in both groups was similar. The awakening headaches were brief (shorter than 30 minutes), and their occurrence and severity correlated with OSA severity. Of the 29 patients with OSA who were treated with continuous positive airway pressure or uvulopalatopharyngoplasty, awakening headaches improved by a mean of 80% compared with minimal improvement of migraine, tension, and cervicogenic headaches. CONCLUSIONS: Awakening headaches are associated with OSA. These headaches are of brief duration, and their occurrence and severity increase with increasing OSA severity. Treatment of OSA with continuous positive airway pressure or uvulopalatopharyngoplasty can reduce these headaches.

Creutzfeldt-Jakob disease presenting with visual blurring, diplopia and visual loss: Heidenhain's variant.

Focal electroencephalographic abnormalities as described in Heidenhain's variant of Creutzfeldt-Jakob disease are uncommon. We report a 73-year-old male presenting with visual symptoms, right hemianopia and rapidly progressive dementia. Myoclonus was synchronous with generalised periodic epileptiform discharges on electroencephalography (EEG). In addition, there were periodic focal sharp waves at the left occipital region. Diffusion-weighted magnetic resonance brain images showed slightly increased signal intensity in the occipital parasagittal area, left more than right. 14-3-3 protein was detected in the cerebrospinal fluid. The patient died within 5 months of presentation.

Refractory seizures in a young army cohort.

This survey covered male Singapore citizens born in 1974 who were medically screened at the age of 18 years before enlistment for compulsory military service. Suspected epileptics were referred to government hospitals for further management. Out of 20,542 men, there were 121 epileptics, giving a cumulative incidence of 5 per 1000 by age 18 years. We had information on 106 (87%) of these individuals and were able to interview them and review their hospital records. Seventy-three of the 106 (69%) epileptics had generalised seizures while 14 (13%) had refractory seizures. There was no statistically significant racial bias amongst these epileptics. Unprovoked afebrile seizures occurred early in these patients, half of whom had seizures onset before 7 years of age. Nine refractory epileptics had a history of febrile seizures, 4 of which were complex febrile seizures. Magnetic resonance imaging identified mesial temporal sclerosis in 2 patients and a hypothalamic lesion in 1 patient. Computed tomographic scans revealed focal cortical atrophy in 2 patients. Nine other patients had normal imaging studies. Nine out of 14 (64%) patients with refractory epilepsy had partial seizures; 4 (29%) had generalised seizures and 1 (7%) was unclassified. This is in contrast to the distribution of the entire cohort of epileptics studied. Two out of 9 patients with refractory partial seizures (gelastic epilepsy and mesial temporal sclerosis) had undergone surgery while 6 of the other 7 patients refused to consider surgery.

New studies on adaptive predictive coding of images using multiplicative autoregressive models.

The authors introduce two new one-dimensional multiplicative autoregressive (MAR) models for adaptive predictive coding of digitized images. The proposed scheme offers a number of advantages. These include easy implementability, a high signal-to-noise ratio at a moderate bit rate, and guaranteed stability of the predictive coder. Results of extensive experimental studies are presented.