Management of psychogenic non-epileptic seizures: a multidisciplinary approach.

The International League against Epilepsy (ILAE) proposed a diagnostic scheme for psychogenic non-epileptic seizure (PNES). The debate on ethical aspects of the diagnostic procedures is ongoing, the treatment is not standardized and management might differ according to age group. The objective was to reach an expert and stakeholder consensus on PNES management. A board comprising adult and child neurologists, neuropsychologists, psychiatrists, pharmacologists, experts in forensic medicine and bioethics as well as patients' representatives was formed. The board chose five main topics regarding PNES: diagnosis; ethical issues; psychiatric comorbidities; psychological treatment; and pharmacological treatment. After a systematic review of the literature, the board met in a consensus conference in Catanzaro (Italy). Further consultations using a model of Delphi panel were held. The global level of evidence for all topics was low. Even though most questions were formulated separately for children/adolescents and adults, no major age-related differences emerged. The board established that the approach to PNES diagnosis should comply with ILAE recommendations. Seizure induction was considered ethical, preferring the least invasive techniques. The board recommended looking carefully for mood disturbances, personality disorders and psychic trauma in persons with PNES and considering cognitive-behavioural therapy as a first-line psychological approach and pharmacological treatment to manage comorbid conditions, namely anxiety and depression. Psychogenic non-epileptic seizure management should be multidisciplinary. High-quality long-term studies are needed to standardize PNES management.

Long-term prognosis of epilepsy, prognostic patterns and drug resistance: a population-based study.

BACKGROUND AND PURPOSE: Seizures in most people with epilepsy remit but prognostic markers are poorly understood. There is also little information on the long-term outcome of people who fail to achieve seizure control despite the use of two antiepileptic drugs (drug resistance). METHODS: People with a validated diagnosis of epilepsy in whom two antiepileptic drugs had failed were identified from primary care records. All were registered with one of 123 family physicians in an area of northern Italy. Remission (uninterrupted seizure freedom lasting 2 years or longer) and prognostic patterns (early remission, late remission, remission followed by relapse, no remission) were determined. RESULTS: In all, 747 individuals (381 men), aged 11 months to 94 years, were followed for 11 045.5 person-years. 428 (59%) were seizure-free. The probability of achieving 2-year remission was 18% at treatment start, 34% at 2 years, 45% at 5, 52% at 10 and 67% at 20 years (terminal remission, 60%). Epilepsy syndrome and drug resistance were the only independent predictors of 2- and 5-year remission. Early remission was seen in 101 people (19%), late remission in 175 (33%), remission followed by relapse in 85 (16%) and no remission in 166 (32%). Treatment response was the only variable associated with differing prognostic patterns. CONCLUSION: The long-term prognosis of epilepsy is favourable in most cases. Early seizure remission is not invariably followed by terminal remission and seizure outcome varies according to well-defined patterns. Prolonged seizure remission and prognostic patterns can be predicted by broad syndromic categories and the failure of two antiepileptic drugs.

Autologous fat grafting for scleroderma-induced digital ulcers. An effective technique in patients with systemic sclerosis.

BACKGROUND: Digital ulcers (DUs) occur in up to 50% of patients with Systemic Sclerosis (SSc). DUs are painful, recurring and lead to functional disability. Management of DUs includes pharmacologic and local therapy, the healing process is slow and the ulcer can become infected or evolve to gangrene. Autologous fat grafting (AFG) is a technique used to promote tissues repair. We used AFG to treat DUs refractory to conventional treatment to enhance healing process. PATIENTS AND METHODS: We treated 9 SSc patients for a total of 15 ulcers. All 9 patients were treated with iv Iloprost. The purified fat tissue was injected at the border of larger ulcers or at the finger base of smaller DUs. The AFG was performed from 2 to 8 months since the ulcer onset. RESULTS: Complete healing occured in 10 DUs and size reduction ≥50% in 2, within 8-12 weeks. In all but 2 patients the pain improved allowing a reduction of analgesics. In the majority of the cases AFG was able to hasten ulcer healing and to reduce pain and the need of pharmacological therapy. The lack of efficacy on healing and pain reduction was observed when the ulcers were long-lasting, located on legs and with concurrent atherosclerotic macroangiopathy. CONCLUSIONS: Surgical resective treatment for finger ulcers in patients affected by SSc is fraught with morbidity and long prolonged recovery. This study introduces a novel minimally invasive approach. The procedure is safe and effective, with short recovery time and local deficient vascularization improvement.

A randomized trial of amantadine and interferon versus interferon alone as initial treatment for chronic hepatitis C.

The aim of this study was to compare, in an open-label study, the efficacy and safety of a combination of interferon (IFN) and amantadine (AMA) with that of IFN alone in previously untreated patients with chronic hepatitis C. A total of 200 patients were randomized to 6 MU of IFN-alpha2a 3 times per week, with 200 mg of AMA daily (n = 99) or to an identical dose of interferon alpha2a (n = 101). Patients were treated for 12 months and observed for 6 months' posttreatment. At the completion of treatment, 28.7% of patients in the monotherapy group and 45.5% in the combination group had a virologic response (P =.014). At 6 months' posttreatment, a sustained virologic response was observed in 16.8% (95% CI: 9-23) of patients with IFN alone versus 29.3% (95% CI: 19-37) of patients who were treated with combination therapy (P =.036). In each of the 2 treatments, genotype was the only predictive parameter for a sustained response. At the logistic regression analysis, therapy and genotype were the only 2 parameters with an independent predictive value. In the combination group, at examination of month 3, hepatitis C virus (HCV)-RNA status had a 97.6% (95% CI: 93-102) positive predictive value and a 50% (95% CI: 37-63) negative predictive value for a sustained virologic clearance. A substantial proportion of naïve patients with chronic hepatitis C have an end-of-treatment and end-of-follow-up virologic and biochemical response to a combination of IFN and AMA. This new treatment appears safe and well tolerated.

The coordinated psychosocial and neurologic care of children with seizures and their families.

SUMMARY: As the medical and surgical management of epilepsy continues to advance, issues associated with the quality of life of patients and their families can be addressed. Whenever associated with other handicaps, such as learning disabilities, attentional or behavioral disorders, and problems in psychological adjustment, dual-diagnosis issues must be identified. To provide comprehensive care for children with epilepsy, a team approach to psychosocial assessment and treatment must be provided and coordinated with neurologic care. When the age-related needs in the life stage of the individual and family are identified, the best possible adaptation of the patient and his or her family can be supported.

Family interactions as targets for intervention to improve social adjustment after epilepsy surgery.

PURPOSE: To identify family interactions associated with psychosocial outcome of epilepsy surgery, to design interventions to improve patient outcome. METHODS: A cross-sectional, case series study of relations among observed family behavior and psychosocial outcome of 43 patients after temporal lobectomy. Videotaped family behavior during family discussion tasks was rated for predominant family affect, affective range, and support of patient autonomy. Multiple regression analyses tested the relation of observed family characteristics to outcomes, controlling for seizure control and other psychological and disease characteristics. RESULTS: Predominant family affect predicted patients' social adjustment independent of postoperative seizure status and other disease characteristics. The relation between predominant affect and social adjustment was stronger among patients with persisting complex partial seizures (CPSs; r = -0.91), versus patients with auras (r = -0.38) and seizure-free patients (r = -0.28; multiple R = 0.71; p < 0.05). Families with a positive affective climate supported patients' autonomy. CONCLUSIONS: Two potential targets were identified for family intervention to improve postsurgical social adjustment: (a) family interactions that support a predominantly positive affective climate, and (b) family interactions that support patient autonomy. These findings are consistent with findings in normal and other clinical populations. They identify specific interactions that give rise to positive versus negative affective climate and support versus undermining of autonomy. These results lay the groundwork for intervention studies targeting these specific family interactions. Such intervention studies would clarify the direction of effect of the observed relationships and would test the efficacy of family intervention for improving psychosocial outcomes for patients with epilepsy.

Activation of the ornithine decarboxylase-polyamine system and induction of c-fos and p53 expression in relation to excitotoxic neuronal apoptosis in normal and microencephalic rats.

Microencephalic rats obtained by gestational treatment with the DNA alkylating agent methylazoxymethanol, show a remarkable lack of sensitivity to excitotoxic neuropathology caused by systemic injections of the convulsant neurotoxin kainic acid. Taking advantage of this, we have studied in these rats, as well as in normal rats, the relationship between the induction of cellular signals supposedly related to cell death and the neuronal apoptosis consequent to kainic acid administration. While normal rats responded to the excitatory insult with a large and relatively long lasting increase of the activity of the enzyme ornithine decarboxylase and of the concentration of putrescine in some brain regions, these alterations were much smaller in microencephalic rats. Expression of c-fos in brain regions sensitive to kainic acid was quicker but lasted a noticeably shorter time in microencephalic rats as compared to normal animals. A profusion of apoptotic neurons, labeled by an in situ technique, were observed in the olfactory cortex, amygdala and hippocampus of normal rats injected with kainic acid, in particular 48 h and 72 h after drug administration. At corresponding time intervals and with similar topographic localization, neurons expressing p53 protein were observed. By contrast, microencephalic rats displayed only in a few cases and in a small number apoptotic neurons in restricted areas of the ventral hippocampus and entorhinal cortex. Noticeably, in these cases small populations of p53-expressing neurons were also present in the same areas. The present observations clearly show that oncogenes such as c-fos and p53, as well as ornithine decarboxylase which behaves as an immediate-early gene in the brain under certain circumstances, undergo noticeably lower and/or shorter induction in microencephalic rats exposed to excitotoxic stimuli. In these rats, therefore, the cellular signalling pathways studied here and related to excitotoxic sensitivity and commitment to cell death are downregulated as a probable consequence of altered brain wiring.

Factors distinguishing families of patients with psychogenic seizures from families of patients with epilepsy.

PURPOSE: Psychogenic seizures (PS) (emotionally based nonelectrical seizures) have been explained by psychodynamics and trauma. However, the family health literature suggests that somatization, of which psychogenic seizures are a form, may run in families and be determined by family patterns of response to distress. This study compared families of patients with PS and those of patients with epilepsy on variables of distress (anxiety and depression) and somatization. METHODS: Eighteen patients (9 with PS and 9 with epilepsy) matched for age and education, and their families answered the Health Status Questionnaire (HSQ), the Weinberger Adjustment Inventory (WAI), the Family Emotional Involvement and Criticism Scale (FEICS), Barsky's Somatization Symptom Inventory (SS), and the Dissociation Experience Scale (DES). Family members' scores were averaged to obtain "family scores." RESULTS: Patients with PS and those with epilepsy did not differ in any of the measures. However, families of patients with PS reported more health problems, distress, and criticism than did families of patients with epilepsy (p < 0.05). Families of patients with PS had increased criticism and somatic problem scores comparable to those of both types of patients. CONCLUSIONS: Although epilepsy causes patients physical and emotional problems, their families are relatively healthy. In contrast, families of patients with PS are more troubled and may unwittingly contribute to PS through family distress, criticism, and tendencies to somatize.

Failure of standard magnetic resonance imaging in patients with refractory temporal lobe epilepsy.

OBJECTIVE: To compare the sensitivity of standard magnetic resonance imaging (MRI) scans done outside an epilepsy center with that of special protocol MRI scans done at an epilepsy center in delineating relevant lesions of the temporal lobe. SUBJECTS: Eighty-four consecutive patients who had temporal lobe resections for refractory temporal lobe epilepsy between January 1, 1993, and February 1, 1996. DESIGN: The reports of findings on standard MRI scans done outside an epilepsy center were compared with the findings of special protocol MRI scans done with 1.5-mm T1-weighted coronal and 3-mm T2-weighted coronal images (no gaps) on a 1.5-T system. Both sets of MRI findings were compared with findings on histologic examination of the resected tissue. RESULTS: Of the 84 patients, 51 had standard MRI scans done outside an epilepsy center; of these, there were 34 patients with normal results, 10 with tumors, 2 with vascular malformations, 2 with hippocampal atrophy, 2 with unclassified abnormalities, and 1 with cortical malformation. In 32 of the 34 patients with normal results of an MRI scan done outside an epilepsy center, abnormalities were found on our special protocol MRI scans. These included hippocampal atrophy in 27 patients, tumors in 2, and cortical malformations in 1. Additionally, all 17 of the abnormalities detected on the standard MRI scans done outside the epilepsy center were identified on our special protocol MRI scans. Important pathologic abnormalities of the temporal lobe were identified in 16 (35%) of the 46 patients with standard MRI scans done outside an epilepsy center and in 44 (96%) with our special protocol MRI scans. In the 29 patients for whom adequate surgical specimens were available and results of standard MRI scans were normal, our special protocol MRI scans showed the abnormality in 27 (93%). CONCLUSIONS: Conventional neuroimaging studies are inadequate for diagnosing hippocampal sclerosis although they fairly readily detect low-grade tumors and vascular malformations. Magnetic resonance imaging scans for the evaluation of patients with refractory temporal lobe epilepsy should be done with a special temporal lobe protocol and read by physicians experienced with the findings in hippocampal sclerosis. Health care dollars are wasted on neuroimaging done for refractory temporal lobe epilepsy outside epilepsy centers.

Hepatitis G virus infection in chronic dialysis patients and kidney transplant recipients.

BACKGROUND: The cloning of the hepatitis G virus (HGV), a novel RNA virus of the Flaviviridae family, has been very recently developed. HGV is known to be parenterally transmitted and has been detected in several patients with cryptogenic hepatitis. However, little information exists about the epidemiology of HGV infection in renal patients. We studied 178 chronic dialysis patients and 11 renal transplant individuals to evaluate prevalence, risk factors, and clinical manifestations of HGV infection in this population. METHODS: Hepatitis G virus infection has been detected by a modified PCR technology which incorporates digoxigenin-labelled nucleotides into the amplicon. Primers from the non-coding region and the NS-5 region of HGV are utilized for a single round amplification. Using a streptavidin surface and a biotin-labelled capture probe, the labelled nucleic acid is bound through the capture probe to the surface, and the amplified nucleic acid is detected using antibody to digoxigenin. RESULTS: HGV RNA was detected in 6% of chronic haemodialysis (HD) patients (11/172), 36% of renal transplant recipients (4/11), and 17% (1/6) of patients on peritoneal dialysis treatment (CAPD). There were no significant differences between HGV positive and negative patients on chronic HD treatment with regard to several demographic, biochemical and virological features. However, the frequency of anti-HCV antibody was significantly higher in HGV-positive than HGV-negative patients (9/11 (82%) vs 51/161 (32%), P = 0.006). In the whole group of HGV RNA-positive patients, 78% (11/14) had a history of blood transfusion requirements, 14/16 (87%) had co-infection with HCV, and 1 (6%) had co-infection with HBsAg. There was no significant association between HCV genotypes and HGV RNA positivity. Six (37.5%) of 16 HGV RNA-positive patients showed raised aminotransferase values in serum. CONCLUSIONS: Patients on maintenance dialysis and kidney transplant recipients are at increased risk of HGV infection; HGV is very frequently associated to hepatitis C co-infection, regardless of HCV genotype. HGV may be transmitted by blood transfusions but transmission routes other than transfusion are possible; 37.5% of HGV RNA-positive patients showed raised serum aminotransferase levels. Further investigations are necessary to clarify the role of HGV infection in the development of liver disease in this clinical setting.

Serologic survey for control of hepatitis C in haemodialysis patients: third-generation assays and analysis of costs.

There is little information about the serologic survey for control of hepatitis C by using third-generation assays among chronic haemodialysis (HD) patients, and no analysis of costs has been made to this end. A serologic survey for control of hepatitis C was performed in 190 HD patients attending a single dialysis unit, using second- and third-generation assays. Costs of both serologic surveys were calculated. Anti-HCV prevalence tested by third-generation assays increased from 25% (48/190) to 28% (53/190) compared to second-generation testing; 56% (9/16) of patients showing uncertain findings by second-generation tests gave unequivocal results by third-generation assays; median duration of HD treatment and raised aminotransferase levels were positively associated (P = 0.004 and P = 0.012, respectively) with anti-HCV detected by third-generation assays. The serologic survey for control of hepatitis C in HD patients at our centre was slightly more expensive by third-generation assays compared to second-generation testing (US$18866 vs US$17200 per year). In summary, the use of third-generation tests largely clarified the uncertain results of second-generation tests; new additional positive patients were detected by third-generation assays compared to second-generation testing. Third-generation assays showed the association of duration of HD treatment and raised aminotransferase levels with anti-HCV antibody, as previously found by first- and second-generation assays. To date, third-generation screening and confirmatory assays seem extremely useful in the serologic survey for control of hepatitis C in HD centres without a considerable outlay.

Apoptosis is induced by excitotoxicity in goldfish retina.

Apoptosis is an important mechanism of cell death that occurs physiologically during development. Recently, it has been shown that the selective pattern of neuronal degeneration in some brain disorders or in excitotoxic animal models, can reveal signs of apoptosis. This work produces evidence that kainic acid, a non-NMDA receptor agonist, induces apoptotic cell death in the goldfish retina. DNA breaks are in situ detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL). This reaction shows a large number of positive cells in the inner nuclear layer 48 hours after intravitreal kainic acid administration. TUNEL staining of apoptotic death was prevented by the non-NMDA glutamate receptor antagonist 6,7-dinitroquinoxaline-2,3-dione (DNQX) but not by the NMDA receptor antagonist MK-801 administration. Ultrastructural changes that occur in kainic acid affected retinal neurons (hypercondensation and clumping of the chromatin and shrinkage of the cytoplasm) are consistent with those described in programmed cell death. Our results indicate that the excitotoxicity of intravitreally injected kainic acid causes the degeneration of those neurons in the goldfish retina, that underwent apoptotic death.

Hepatitis C virus genotypes in chronic dialysis patients.

BACKGROUND: Hepatitis C virus (HCV) infection is highly prevalent in dialysis patients. To further characterize HCV infection in this patient population, we studied the distribution of viral genotypes in 55 patients undergoing chronic dialysis treatment with seropositivity for HCV markers. METHODS: Thirty-two of 55 (58%) patients showed HCV RNA in the serum using reverse transcription polymerase chain reaction (RT-PCR) in the 5'-untranslated region (UTR) of the viral genome. HCV genotyping was performed using biotinylated type-specific oligonucleotide probes after hybridization with amplified sample material. RESULTS: HCV subtype 2a was dominant (56%), followed by HCV subtype 1b (31%), type 3 (3%) and 4 (3%). There was no association between demographic or clinical features of this cohort and HCV genotype. Genotype dependence was observed for antibody response toward the NS4 (c 100-3 and 5-1-1) proteins, which was infrequent in genotype 2a carriers compared with genotype 1b (p = 0.004). CONCLUSIONS: HCV subtype 2a was dominant in our cohort of anti-HCV-positive dialysis patients; there was no association between HCV genotypes and demographic or clinical features of patients; the absence of antibody response toward the NS4-related antigens was frequent in genotype 2a carriers and may serve to predict responses to interferon therapy. The relative homogeneity of the viral population in dialysis patients attending our unit suggests a nosocomial transmission of HCV in this clinical setting.

IgM antibody response to hepatitis C virus in end-stage renal disease.

BACKGROUND: In HBV infection, as in other viral diseases, antibodies of the IgM class are associated with acute or ongoing infection. In contrast, the significance of this antibody in HCV infection is unclear and data regarding end-stage renal disease (ESRD) patients are lacking. METHODS: We tested sera from 78 ESRD patients (66 chronic dialysis patients, 12 renal allograft recipients) showing anti-HCV IgG antibody, for serum anti-HCV IgM core antibody. A specific solid-phase enzyme-linked immunoassay (HCV IgM EIA, Abbot) was used. In all patients serum HCV RNA was detected by RT-PCR technique, with primers from the 5' untranslated region of the viral genome. RESULTS: Prevalence of anti-HCV IgM core antibody was 22% (17/78). We observed association between prevalence of anti-HCV IgM core antibody and frequency of HCV RNA in the serum. Thus 15 of 45 (33%) sera containing HCV RNA also contained anti-HCV IgM, while two of 33 (6%) HCV RNA negative sera showed anti-HCV IgM core antibody (P = 0.01). There was a significant relationship between absorbance values of anti-HCV IgM core antibody and NS3 (P = 0.01), NS5 (P = 0.04), and core (P = 0.0001) reactivity in RIBA-2 and RIBA-3 assays. Optical density values of anti-HCV IgM were significantly associated with the number of reactive bands in RIBA-2 (P = 0.04) and RIBA-3 (P = 0.03) assays. CONCLUSIONS: 22% of ESRD patients with anti-HCV IgG activity showed anti-HCV IgM core antibody in the serum. Anti-HCV IgM activity seems to correlate positively with HCV viraemia in ESRD population. Testing for this antibody may be useful as a serological marker to indicate the presence of ongoing HCV infection.

Virological and histological features of hepatitis C virus (HCV) infection in kidney transplant recipients.

BACKGROUND: Although there are some reports regarding prevalence of anti-HCV antibodies in kidney transplant patients, there are scarce data about viraemia, genotyping and liver histology of HCV infection in kidney transplant recipients. METHODS: We studied the prevalence of anti-HCV antibodies by second-generation screening and confirmatory assays in a cohort of 73 renal allograft recipients. All patients were tested for serum HCV RNA using reverse transcription polymerase chain reaction in the 5'-untranslated region (UTR) of the viral genome. HCV RNA positive patients were subjected to genotype analysis using biotinylated type-specific oligonucleotide probes after hybridization with amplified sample material. Eleven of 73 patients showing raised aminotransferase levels underwent hepatic biopsy. RESULTS: Fifteen of 73 (20%) patients were determined anti-HCV positive. Eleven of 73 (15%) showed detectable serum HCV RNA; no viraemic, seronegative patients were identified. Genotyping showed that HCV subtype 2a was dominant (64%), followed by HCV subtypes 1b (27%) and 1a (9%). Six of 11 (54%) HCV RNA patients and 12 of 62 (19%) HCV RNA negative patients showed raised aminotransferase levels (P = 0.03). Liver biopsies showed histological features of chronic hepatitis with mild or moderate degrees of activity. CONCLUSIONS: The prevalence of anti-HCV antibodies and HCV viraemia was 20% and 15% respectively; there was a good association between anti-HCV anti-bodies and HCV viraemia; hepatic enzyme levels were good indicators of ongoing HCV infection; HCV subtype 2a was prevalent; liver histology showed histological characteristics of chronic hepatitis with mild or moderate degrees of activity.

Recombinant hepatitis B vaccine use in chronic hemodialysis patients. Long-term evaluation and cost-effectiveness analysis.

The prevalence of hepatitis B virus (HBV) infection in our unit was 45% (86/190); there were 77 (40.5%) and 9 (4.7%) patients with previous and persistent HBV infection, respectively. Recombinant hepatitis B vaccine was given to 118 chronic HD patients with a regimen of 3 double doses administered intramuscularly at 0, 1 and 2 months, obtaining a seroprotection rate of 67% (79/118), 57% (45/79) being high responders. At month 24, 78% (40/51) maintained protective levels of anti-HBs, 45% (18/40) of them being high responders. There was a statistically significant difference between responder and non-responder patients with regard to nutritional parameters such as serum total proteins and mean levels of transferrinemia. The number of diabetic patients was significantly increased in the nonresponder group. Patients with persistent antibodies ('persistent responders') were younger and had a shorter duration of HD treatment compared to those responders who rapidly lost anti-HBs ('transient responders'). Serological positivity for antibodies against hepatitis B core antigen significantly facilitates the decrease of anti-HBs antibodies over time. We detected seven episodes of HBV infection among HD patients at our unit before the beginning of the vaccination program. On the contrary, there were no episodes of HBV infection among responder vaccinees during the 24-month follow-up period. After the initial cost of vaccination, a savings of US$ 3,272 per year was realized by the elimination of frequent serologic screening of vaccine responders.

Virological characteristics of hepatitis C virus infection in chronic hemodialysis patients: a cross-sectional study.

Detection of hepatitis C virus viremia (HCV RNA) in serum of hemodialysis (HD) patients is crucial for documenting ongoing infection because the clinical and epidemiological importance of anti-HCV positivity is not clear. HCV viremia was studied in 104 HD patients by reverse transcription polymerase chain reaction (RT PCR) using primers localized in the 5' non-coding region of the viral genome. We used two different methods to detect HCV RNA: a direct PCR amplification of HCV RNA from human serum, and a standard RT PCR procedure (requiring the RNA extraction step). There were 50 (48%) anti-HCV positive patients in this population. Twenty-two (21.1%) out of 104 patients showed HCV RNA in serum by standard RT PCR technique: they belonged to the anti-HCV positive patient group, whereas all anti-HCV negative patients were HCV RNA negative. Prevalence of HCV RNA was more than doubled when standard RT PCR was used compared to direct RT PCR protocol. There was a good association between serum HCV RNA and circulating anti-HCV antibodies, tested by second-generation ELISA and RIBA assays. HCV viremia was not associated with either the presence or the absence of a particular RIBA antibody specificity. AST and ALT levels had no predictive value for HCV viremia, because they were repeatedly normal in the majority of viremic patients (16/22: 73%).(ABSTRACT TRUNCATED AT 250 WORDS)

Ictal contralateral paresis in complex partial seizures.

Certain behaviors that occur during a complex partial seizure (CPS) are useful in lateralizing the side of seizure onset. In 5 (5.3%) of 94 consecutive patients with partial epilepsy, we observed ictal unilateral arm and hand paresis during 27 of 34 CPS. In all these seizures, this behavior occurred contralateral to an epileptogenic temporal lobe, as determined by video-EEG monitoring and surgical outcome. In 5 of the 27 seizures, an observer demonstrated that the paretic arm and hand were flaccid. None of these patients had postictal (Todd's) paralysis. In most of the seizures, the arm ipsilateral to seizure onset had simultaneous purposeful movements or automatisms, sometimes with awkward posturing. Ictal unilateral paresis is distinctly different from ictal dystonia or postictal paralysis and consistently lateralizes seizure onset to the contralateral temporal lobe. Recognition of this particular ictal behavior and comparison to other simultaneous behaviors can aid in the lateralization and possibly localization of the epileptogenic zone.