Childhood absence epilepsy: evolution and prognostic factors

PURPOSE: To evaluate how diagnostic criteria influence remission rates for patients with childhood absence epilepsy (CAE) and to assess clinical and EEG parameters as predictors of outcome. METHODS: One hundred nineteen patients were diagnosed with CAE, according to International League Against Epilepsy (ILAE) classification criteria. They were subsequently evaluated according to stricter diagnostic criteria. Sixty-two subjects fulfilled these criteria as group 2; 57 did not and constituted group 1. Diagnostic parameters that prevented patients of group 1 from entering group 2, and variables such as sex, familial history of generalized epilepsy, and personal history of febrile convulsions also were tested as prognostic factors for terminal remission. RESULTS: Compared with those in group 1, patients of group 2 had significantly higher rates of seizure control (95% vs. 77%), higher rates of terminal remission (82% vs. 51%), fewer generalized tonic-clonic seizures (8% vs. 30%), and shorter mean periods of treatment (2.2 vs. 3.8 years). Significantly fewer patients were receiving polytherapy in group 2 than in group 1 (11% vs. 47%), and fewer patients had seizure relapses at antiepileptic drug discontinuation (0 vs. 22%). CONCLUSIONS: Remission rates of patients with CAE are greatly influenced by the classification criteria used for selection. Stricter diagnostic criteria allow the definition of a homogeneous group of patients with excellent prognosis. Factors predicting unfavorable prognosis were generalized tonic-clonic seizures in the active stage of absences, myoclonic jerks, eyelid myoclonia or perioral myoclonia, and EEG features atypical for CAE.     

不明原因栓塞性卒中的临床研究

目的 研究不明原因栓塞性卒中（embolic stroke of undetermined source,ESUS）住院患者的一般情况、 危险因素及治疗情况。 方法 检索2003年1月至2014年12月在北京安贞医院神经内科住院的急性缺血性卒中患者,筛选其中符 合ESUS诊断标准的为ESUS组,其他卒中亚型为对照组,比较两组间一般情况、危险因素及治疗情况。 结果 共检出初发急性缺血性卒中1296例,筛选完成诊断ESUS必须检查项目患者200例,其中ESUS占 46.5%（93/200例）,大动脉硬化性卒中26%（52/200例）,心源性卒中25%（50/200例）,腔隙性脑梗 死2.5%（5/200例）,隐源性卒中（cryptogenic stroke,CS）0例;ESUS患者卒中危险因素与对照组比较 基本一致;ESUS患者中94.6%（88/93例）在住院期间及出院后二级预防应用抗血小板治疗,而5.4% 患者（5/93例）因梗死后渗血未应用抗栓治疗,所有入选ESUS的患者均未使用华法林或新型口服抗 凝剂抗凝治疗。 结论 ESUS作为新的卒中亚型在临床工作中并不少见,临床应完善诊断ESUS所需的检查项目,提高 其诊断率,进一步细化卒中亚型,从而提供更有针对性的治疗。     

Prospective analysis of risk factors for nursing home placement of dementia patients.

OBJECTIVE: To examine risk factors for nursing home placement in a community-based dementia cohort. METHODS: Cognitively normal participants and cognitively impaired patients from a large AD Patient Registry were followed from diagnosis to placement, death, or last follow-up. This included over 3,600 person-years of surveillance. The normal group included 473 participants who did not, at any point, meet Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised (DSM-III-R) criteria for dementia. The patient group included 512 patients who met DSM-III-R criteria for dementia or criteria for mild cognitive impairment at diagnosis. Demographic, medical, social, cognitive, behavioral, and functional predictors of time to placement were examined using Cox modeling. RESULTS: In the normal group, only 21 people (4%) required nursing home placement. With subjects, enrollment year, age at initial evaluation, being widowed, and living in a retirement community were associated with time to placement in separate univariate analyses. Of 512 cognitively impaired patients, 203 (39.6%) were placed in nursing homes. Median time from diagnosis to placement was 5.3 years. Within the patient sample, four predictors were determined to be associated with time to nursing home placement. These included gender, enrollment year, functional status, and cognitive score. Interactions were present for functional status with cognitive score and enrollment year. CONCLUSION: In patients with dementia who are within 5 years of diagnosis, placement rates of approximately 10% per year can be expected. Disease severity indices including degree of cognitive and functional impairment are primary risk factors for placement.     

帕金森病合并不宁腿综合征26例临床分析

目的探讨帕金森病（Parkinson’s disease,PD）患者合并不宁腿综合征（restless leg syndrome,RLS）的临床特点,且进一步研究PD患者合并RLS的相关因素。方法选取确诊的119例PD患者,根据是否合并RLS分为伴RLS组和单纯PD组,分别比较2组的一般状况、病史、临床表现、严重程度、合并症、治疗情况等临床资料。结果 119例PD患者中26例合并RLS,发生率为20.8%,且RLS均出现在PD症状后。2组在UPDRS、HAMD、HAMA、PSQI上有统计学差异（P〈0.05）,而在一般状况、主要症状、左旋多巴治疗等方面均未见统计学差异（P〉0.05）。另外,发现左旋多巴的日剂量与RLS严重度之间存在正相关关系,即服用左旋多巴剂量越大,RLS程度越重。结论 RLS可能是PD病程中出现的一种并发症。PD运动症状较严重、并发症较多时合并RLS的可能性相对较大,随着多巴胺能药物剂量的加大,RLS的病情可能加重。     

帕金森病合并不宁腿综合征的相关因素分析

目的研究帕金森病(Parkinson's disease,PD)患者合并不宁腿综合征(restless leg syndrome,RLS)的特点,进一步探讨PD患者易合并RLS的相关因素。方法选取门诊诊断为PD的102例患者,根据是否合并RLS将入选病例分为不伴RLS的PD组和伴RLS的PD组,分别比较两组的一般状况、病史、临床表现、严重程度评分以及治疗等临床资料,进行单因素统计分析。结果102例PD患者中有28例合并有RLS,发生率为27·5%。其中有1例为诊断PD之前即存在RLS,其余均在出现PD症状后才出现RLS症状。两组在HAMD评分上有统计学差异(P0.05),而在一般状况,主要症状,左旋多巴的治疗以及蒙特利尔,UPDRS评分等方面均未见统计学差异(P0.05)。PD患者中RLS的发生与抑郁情绪有着较密切的关系,另外发现PD发病年龄与RLS的严重程度呈负相关。PD患者的发病年龄越小,RLS的程度越严重。结论PD患者抑郁状态时合并RLS的可能性较大。PD合并RLS患者,PD的发病年龄越小,RLS程度越严重。     

Is there any relation between insulin resistance and cognitive function in the elderly?

BACKGROUND: Vascular risk factors are blamed as being involved in the pathogenesis of cognitive dysfunction in the elderly. Alzheimer's disease or vascular-type dementia could be part of a metabolic syndrome. The aim of this study was to evaluate whether there is any relation between insulin resistance and cognitive status of the elderly regarding normal, mild cognitive impairment (MCI), Alzheimer's disease (AD), vascular dementia (VaD) and mixed dementia.METHODS: 267 elderly patients admitted to an outpatient geriatrics clinic were evaluated medically and cognitively in this study. The patients were diagnosed using ARDRA and DSM-IV criteria for AD; NINDS-AIREN and DSM-IV criteria for VaD; and Petersen criteria for MCI. Insulin resistance was calculated using both the homeostasis model assessment (HOMA) and quantitative insulin sensitivity check index (QUICKI) formulas.RESULTS: The mean values of HOMA and QUICKI scores were 2.79 (SD+/-3.56) and 0.346 (SD+/-0.036) for the normal group, 2.81 (SD+/-3.06) and 0.354 (SD+/-0.047) for AD group, 2.20 (SD+/-1.82) and 0.360 (SD+/-0.048) for VaD group, 2.87 (SD+/-1.81) and 0.339 (SD+/-0.038) for mixed dementia group, 2.79 (SD+/-2.81) and 0,349 (SD+/-0.042) for MCI group, respectively. There were no statistically significant differences between HOMA and QUICKI scores of all the groups.CONCLUSION: This is the first study of the possible relation between insulin resistance and cognitive function in people categorized according to five forms of cognitive status. Unfortunately the results do not allow generalizations. Further prospective cohort studies that follow a normal cognitive group and MCI patients with and without insulin resistance are necessary.     

Consultation-liaison service in the general hospital: effects of cognitive-behavioral therapy in patients with physical nonspecific symptoms

Nearly 15% of patients referred to a general hospital psychological medicine consultation service met DSM criteria for somatoform disorders or showed psychological factors affecting physical conditions. In a case-control control study of patients meeting these diagnostic criteria. outcomes were compared of 21 consecutively referred patients who received a course of cognitive-behavioral therapy (CBT) in addition to standard hospital treatment (SHT) and another 21 patients who received SHT alone. Compared with the SHT group, those who received CBT treatment showed significantly decreased bodily complaints and negative mood, better insight into the psychosomatic causes of their complaints, and a high motivation for subsequent psychotherapy.     

Paradoxical brain embolism may not be uncommon-Prospective study in acute ischemic stroke

Abstract Background Proving that right-to-left shunt (RLS) represents the precise causative mechanism in ischemic stroke patients with RLS is difficult. The aim of this study was to examine the frequency and clarify the clinical characteristics of paradoxical brain embolism (PBE). Methods We prospectively enrolled consecutive acute ischemic stroke patients, who underwent transcranial Doppler and/or transesophageal echocardiography. For patients with RLS, diagnostic criteria for PBE were established as follows: 1) brain images suggesting embolic strokes; 2) presence of deep venous thrombus or pulmonary embolism; and 3) absence of any embolic sources. Patients were divided into 4 groups: patients meeting all 3 criteria (Definite); fulfilling 2 criteria (Probable); fulfilling 1 or 0 criteria (Possible); and patients without RLS (Non-RLS). Results A total of 240 subjects were analyzed for this study. The Definite group comprised 5% of patients, and displayed significantly more females (p = 0.038), and infarcts involving both anterior and posterior circulations (p < 0.001). Patients having neither hypertension nor diabetes mellitus also predominantly belonged to the Definite group (p < 0.001). Conclusions Clinical characteristics of PBE are a female preponderance, infarcts affecting both anterior and posterior circulations, and an absence of risk factors.     

Preliminary evidence of striatal D2 receptor density as a possible biological marker of prognosis in naive schizophrenic patients

With the aim of investigating a possible biological marker of prognosis in schizophrenia, the relationship between striatal dopaminergic D2 receptor (D2R) density and clinical prognostic factors was studied in an initial sample of nine neuroleptic-naive schizophrenic patients. Previous psychosocial adaptation was evaluated by means of the Premorbid Adjustment Scale (PAS). Based on the four DSM-IV criteria in schizophreniform disorder for good prognosis, patients were divided in two groups: good prognosis if > or =2 criteria were met (n=5) and poor prognosis if <2 criteria were met (n=4). D2R density was assessed by means of 123I-IBZM single photon emission computed tomography (SPECT) and striatum/occipital uptake ratios (S/O). S/O ratios previously obtained from a control group of nine age- and sex-matched healthy volunteers were used for comparison. RESULTS: Patients with poor prognosis showed a higher S/O ratio (mean=1.94, range=1.93-1.98) than patients with good prognosis (mean=1.64, range=1.52-1.79) and the control group (mean=1.69, range=1.51-1.85) [analysis of variance (ANOVA) F=10.628, df=2, P=.001, post hoc Scheffé P<.005]. PAS scores were significantly different between patients with good and poor prognosis (40+/-9.39 vs. 84.25+/-26, Mann-Whitney U-test P=.014). A direct correlation of S/O ratios with PAS scores was found (Spearman r=.72, P=.028). CONCLUSIONS: Striatal D2R density in naive schizophrenic patients may be related to DSM-IV prognostic factors and premorbid adjustment criteria (PAS). If these preliminary results are confirmed, striatal D2R density might predict premorbid and clinical features associated with poor prognosis in neuroleptic-naive patients.     

Double crush syndrome: an analysis of age, gender and body mass index

OBJECTIVES: The aim of this study is to evaluate the role of age, gender, body mass index (BMI), wrist ratio and median sensory nerve conduction velocity as independent risk factors for double crush syndrome (DCS) and to analyze the strength of association of these factors. PATIENTS AND METHODS: We have undertaken a case-control study in 142 patients (125 females) with carpal tunnel syndrome (CTS) and 109 controls. Based on clinical and electrophysiologic criteria 106 pure CTS patients and 36 DCS patients as well as 62 female and 47 male control subjects were selected from patients and their relatives referred to our tertiary referral hospital. Totally nerve conduction studies and electromyographic examination were done in 201 hands. Height, weight, BMI, wrist width, depth, circumference and ratio were measured in all patients and control group. Mean values of different risk factors for DCS group and controls were measured. A logistic regression analysis was conducted to evaluate odds ratio of different risk factors. RESULTS: The mean values for age was greater in DCS patients than CTS group. Male gender and increasing age had odds ratio of 4.19 (CI 95%: 1.35-12.96) and 1.13 (CI 95%: 1.07-1.19), respectively. CONCLUSION: Our study confirms that male gender and increased age are independent risk factors for DCS. We suggest that in elderly men presenting with CTS, electrophysiologic screening for cervical radiculopathy should be considered because the treatment of DCS differs from pure CTS.     

Post-traumatic hydrocephalus

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The incidence of symptomatic PTH ranges from 0.7%-29%. If CT criteria of ventriculomegaly are used the incidence has been reported to be from 30%-86%. Differences in diagnostic criteria and classification have contributed to the variation in reported incidence. The diagnosis of PTH is established using a combination of clinical, imaging and physiologic data. Symptomatic PTH is to be distinguished from post-traumatic ventriculomegaly resulting from atrophy. Symptomatic PTH patients are likely to improve when treated by shunting. Ventriculomegaly secondary to atrophy is less likely to respond to shunting. A series of traumatic brain injury patients at Wayne State University has been followed since 1989. The overall incidence of shunt placement in this group is 3.65%. Future studies of PTH should be aimed at refining diagnostic classification and criteria. Analysis of a large PTH population may then identify alterable risk factors in the early post-traumatic brain injury period. Minimizing these factors will help prevent subsequent PTH and obviate the need for shunting.     

Significance of aortic atherosclerotic disease in possibly embolic stroke: 64-multidetector row computed tomography study

The usefulness of 64-multidetector row computed tomography (MDCT) for the evaluation of aortic atherosclerotic disease (AAD), a potential source of cerebral emboli, has recently been suggested. We aimed to assess the significance of AAD by using MDCT in patients who are suspected to have had embolic stroke clinically or radiologically but without evident cardioembolic source (possibly embolic stroke, or PES). From 5/2007 to 10/2007, patients who were presented with acute ischemic stroke, met predefined criteria for PES, and underwent MDCT, were found in a prospective stroke registry (PES group). High-risk AAD was defined as thrombus, ulceration, and a ≥4 mm thickness of atherosclerotic plaque in the ascending aorta and aortic arch on MDCT. For comparison, patients who were hospitalized due to non-embolic stroke (NES) during the study period and who underwent MDCT for the purpose of screening of coronary artery disease were selected (NES group). Among a total of 336 patients with acute ischemic stroke, 57 (20.0%) satisfied the criteria for PES, and MDCT was performed in 50 of these 57 patients. One-hundred six patients were selected as the NES group. The PES group had significantly higher prevalence of high-risk AAD than the NES group did (38.0 vs. 13.2%, P < 0.01). The odds ratio of high-risk AAD was 4.03 (95% confidence interval, 1.81–8.98) and this result remained significant after adjustment for risk factors of atherosclerosis. This study suggests the etiologic role of aortic atherosclerosis detected by MDCT in patients who are assumed to have had embolic stroke but without evident embolic source.     

An evaluation of gender, body mass index, wrist circumference and wrist ratio as independent risk factors for carpal tunnel syndrome

OBJECTIVES: The aim of this study was to evaluate the role of gender, body mass index (BMI), wrist ratio (WR) and wrist circumference as independent risk factors for carpal tunnel syndrome (CTS) and to analyze the strength of association of these factors. METHODS: We have undertaken a case-control study in 128 CTS patients and 109 controls. Based on clinical and electrophysiologic criteria, 109 female and 19 male CTS patients as well as 62 female and 47 male control subjects were selected from patients and their relatives referred to our hospital. In total, 179 hands with CTS in three groups of severity (mild, moderate and severe) were examined. Height, weight, BMI, wrist width, depth, circumference and ratio were measured in all patients and control group. Mean values of different risk factors for CTS group and controls were measured. A logistic regression analysis was conducted to evaluate odds ratio of different risk factors. RESULTS: The mean values for BMI and WR were greater in CTS patients than in the subject group. Thirty-four, 89 and 57 patients had mild, moderate and severe CTS, respectively. Mean age, BMI, wrist circumference and ratio were not statistically significant in the three groups. Female gender, increased BMI and increased WR had odds ratio of 9.95, 1.75 and 1.12, respectively. CONCLUSION: Our study confirms that female gender, obesity and square wrists are independent risk factors for CTS.     

The interrelations of migraine, vertigo, and migrainous vertigo

OBJECTIVE: To assess the prevalence of migrainous vertigo in patients with migraine and in patients with vertigo according to explicit diagnostic criteria that are presented for discussion. METHODS: The authors prospectively evaluated 200 consecutive patients from a dizziness clinic and 200 patients from a migraine clinic for migrainous vertigo based on the following criteria: 1) recurrent vestibular symptoms (rotatory/positional vertigo, other illusory self or object motion, head motion intolerance); 2) migraine according to the criteria of the International Headache Society (IHS); 3) at least one of the following migrainous symptoms during at least two vertiginous attacks: migrainous headache, photophobia, phonophobia, visual or other auras; and 4) other causes ruled out by appropriate investigations. In addition, the authors compared the prevalence of migraine according to the IHS criteria in the dizziness clinic group with a sex- and age-matched control group of 200 orthopedic patients. RESULTS: The prevalence of migraine according to the IHS criteria was higher in the dizziness clinic group (38%) compared with the age- and sex-matched control group (24%, p < 0.01). The prevalence of migrainous vertigo was 7% in the dizziness clinic group, and 9% in the migraine clinic group. In 15 of 33 patients with migrainous vertigo, vertigo was regularly associated with migrainous headache. In 16 patients, vertigo occurred both with and without headache, and in two patients headache and vertigo never occurred together. The duration of attacks varied from minutes to days. CONCLUSION: These results substantiate the epidemiologic association between migraine and vertigo and indicate that migrainous vertigo affects a significant proportion of patients both in dizziness and headache clinics.     

Assessment and psychotherapeutic options of patients with somatoform disorders and a claim for invalidity pensioning

Difficulties in the assessment of patients with somatoform disorders and a claim for social security benefits or invalidity pensioning pose a considerable challenge to the medical community. Within the process of delivering a medical expert's opinion, psychiatric and psychological factors often are underestimated. There are ample recommendations to apply specific criteria within the medical expert's report, but there are no empirical studies confirming that these criteria are really used and prognostically valuable. Especially, despite the growing numbers of psychosomatic in-patients and the thereby heightened socioeconomic importance, there are nearly no catamnestic studies which sufficiently evaluate the results of psychotherapy in the specific group of patients with somatoform disorders and a pending desire for financial compensation alone. The rare available data provides a nearly disastrous impression of psychotherapy results in this patient group. This review article highlights important problems of this special patient group and provides some suggestions concerning the further handling of the addressed issues.     

Idiopathic generalized epilepsy with absences: syndrome classification

In a cohort of 275 Caucasians with a broad IGE phenotype, patients with absences were classified. Criteria of the 1989 Commission on Classification of the International League Against Epilepsy for Childhood Absence Epilepsy (CAE 1989 criteria) were compared with the stricter criteria of the ILAE Task Force for Classification and Terminology (CAE 2005 criteria). Among the 129 patients with absences without significant myoclonus, 50 had juvenile absence epilepsy 44 had CAE according to the CAE 1989 criteria and only 30 had CAE according to the CAE 2005 criteria. We found a significantly better outcome in patients considered as CAE by the CAE 2005 criteria, compared with those excluded. Strict criteria for classification of absence syndromes leave many patients unclassified. However, diagnostic criteria used to classify CAE patients have prognostic significance. We propose that patients are classified as having benign CAE or as having CAE with the adverse prognostic factors indicated.     

Life Events,Motives, and Precipitating Factors in Parasuicide Among Borderline Patients

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.     

Life events, motives, and precipitating factors in parasuicide among borderline patients.

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.     

An empirical study of diagnostic criteria for delirium

OBJECTIVE: The objective of this study was to determine empirically how many patients are identified as delirious or nondelirious according to DMS-III, DMS-III-R, and ICD-10 criteria. METHOD: Daily, a trained research assistant using a structured instrument to detect the presence of symptoms of delirium evaluated 325 elderly patients who were admitted to a general hospital for acute medical problems. Each patient's symptoms were then compared with these diagnostic criteria sets to determine if the patient met criteria for delirium. RESULTS: DSM-III criteria were the most inclusive: they identified 125 patients as delirious. DSM-III-R identified a somewhat different group of 106 patients as delirious. ICD-10 criteria identified only 30 patients as delirious. CONCLUSIONS: The development of new criteria for delirium (e.g., DSM-IV) will have to balance the need to define a pure group of patients for research purposes with the need to include cases of clinical interest. Changes in criteria should be based on data such as those presented in this paper.