Outcome after temporal lobectomy in bilateral temporal lobe epilepsy

We determined how noninvasive presurgical data relate to prognosis after temporal lobectomy in patients with independent bilateral temporal lobe (IBTL) complex partial seizures on the intracranial electroencephalogram (EEG). Between 1986 and 1994, 28 patients had IBTL seizures on intracranial EEG. Fifteen of these 28 patients underwent temporal lobectomy and 13 were not offered surgery. Of the 15 patients who had surgery, 10 patients became seizure-free. Magnetic resonance imaging (MRI) and the Wada test were the only variables associated with a seizure-free outcome. Seven of 10 seizure-free patients had a lateralized Wada result or the presence of unilateral hippocampal sclerosis, whereas none of the patients with persistent seizures had either of these findings. Variables not found to be predictive of a seizure-free outcome included location of scalp interictal spikes, degree of seizure-onset laterality, presence of early epilepsy risk factor, duration of epilepsy, and full-scale intelligence quotient. We conclude that MRI and the Wada test provide information of prognostic value in patients with bilateral temporal seizures independent of intracranial EEG data.     

Trimipramine: A challenge to current concepts on antidepressives

Although it is chemically a classical tricyclic antidepressant agent, trimipramine shows atypical pharmacological properties. Its well-documented antidepressant action cannot be explained by noradrenaline or serotonin reuptake inhibition or by a down-regulation of β-adrenoceptors. Furthermore, its receptor affinity profile resembles more that of clozapine, a neuroleptic drug, than that of tricyclic antidepressants. Trimipramine does not reduce, but rather increases, rapid eye movement sleep. It stimulates nocturnal prolactin secretion and inhibits nocturnal cortisol secretion, and may act at the level of the hypothalamus on corticotropin-releasing hormone secretion. Trimipramine is of particular value in depressed patients with insomnia, and it has been shown to be effective in the therapy of primary insomnia. As the pharmacological profile indicates, and an open clinical study has shown, trimipramine might also be active as an antipsychotic. The drug is both a tool for increasing our understanding of depression and a potential therapy for several psychiatric disorders.     

Decision making and results in subtotal and total lower leg amputations: Reconstruction versus amputation

As a result of modern therapeutic and technological advances, the surgeon has the ability to salvage even the most severely injured lower limbs. However, the success of replantation nowadays is no longer measured simply on the basis of restoration of viability but also on functional outcome compared with primary amputation with early prosthetic fitting, the risk to the patient during and after replantation and the overall time of treatment which should not exceed 2 years. Although every major limb replantation has to be considered individually, the decision-making process for reconstruction (replantation/revascularisation) versus amputation with subsequent early prosthetic fitting should be determined by objective criteria. Based on personal experience and an extensive literature search, an algorithm for treatment of amputation or amputation-like injuries to the lower leg has been developed and tested in a clinical study. A 100% viability success rate was achieved. There was not only a significant increase in the percentage of “functional extremities” but also a doubling in grade I results. Moreover, there was a 50% reduction in patients presenting a “non-functional extremity”, and no patient required a secondary re-amputation. The replantation risk (e.g., risk of severe systemic disturbance during and/or after replantation) was about 16.6% (2/12) in our study. There was a significant decrease in the postoperative complication rate and no patient died during or after replantation. Based on our experience, if reconstruction in subtotal or total lower leg amputation is done for a well-selected patient group, good functional results with a reasonable replantation risk and a reasonable time for social re-integration can be achieved. © 1995 Wiley-Liss, Inc.     

DNA analysis of HLA-DR, DQ and DP genes in pauciarticular juvenile rheumatoid arthritis.

HLA-DR, DQ, and DP alleles were determined by restriction fragment length polymorphism (RFLP) and oligonucleotide hybridization analysis in 50 Caucasian children with pauciarticular juvenile rheumatoid arthritis (PaJRA) and 82 controls. There was an increased frequency of DR5, DRw8, and DQw4, as well as individual DQ alpha and beta chains, DQA*0401 and DQB1*0402, respectively, in this group of patients. There was an absolute association between DRw8, DQw4, DQA1*0401, and DQB1*0402 in the patient population. HLA-DPw2.1 was also increased in frequency. There was little evidence of linkage disequilibrium found between DPw2.1 and DR5, DRw8, or DQw4. These MHC Class II associations were more characteristic of those patients with young age of onset (less than 5 years), rather than those with onset greater than or equal to 5 years of age. Our data confirmed the previous associations of HLA-DR5, DRw8, and DPw2.1 with PaJRA and suggested a new association for DQ alpha and beta genes in the clinical expression of this disease.     

Leukemia,lymphoma, and multiple myeloma following selected medical conditions

The role of selected prior medical conditions in the etiology of hematopoietic malignancies was examined in a case-control study of members of two regional branches of the Kaiser Permanente Medical Care Program (USA). Past history of chronic infectious, autoimmune, allergic, and musculoskeletal disorders was abstracted from medical records for leukemia (n = 299), non-Hodgkin's lymphoma (NHL, n = 100), and multiple myeloma (n = 175) cases and matched controls (n = 787). Little difference was found between cases and controls for most of the chronic conditions evaluated, including sinusitis, carbuncles, urinary tract infections, pelvic infections, herpes zoster, asthma, rheumatoid arthritis, psoriasis, bursitis, and gout. Only three statistically significant elevated risks were found, i.e., with combined disc disease myeloma among patients with prior eczema and disk and other musculoskeletal conditions, and NHL following tuberculosis. Only two of these associations showed consistent patterns by sex and geographic region (myeloma with eczema and with musculoskeletal conditions). While prior history of eczema and musculoskeletal conditions may slightly increase risk of myeloma, this study provided little if any support for an association of chronic infectious, autoimmune, allergic, and musculoskeletal conditions with subsequent occurrence of the leukemias or NHL. Additionally, these data did not support a role for chronic antigenic stimulation, as defined in previous epidemiologic studies, in the etiology of hematopoietic malignancies.Ms Doody and Drs Linet, Pottern, Boice, and Fraumeni are with the Epidemiology and Biostatistics Program, National Cancer Institute. Dr Glass is with the Kaiser Permanente Medical Care Program, Northwest Region, Portland, Oregon, USA. Dr Friedman is with the Kaiser Permanente Medical Care Program, Northern California Region, Oakland, California, USA. Address correspondence to Ms Doody, Radiation Epidemiology Branch, National Cancer Institute, Executive Plaza North, Room 408, Bethesda, MD 20892, USA. This research was supported in part by National Cancer Institute contracts NO1-CP-01047, NO1-CP-01054, NO1-CP-11009, NO1-CP-11037, NO1-CP-31035, and NO1-CP-61006.     

Staphylococcus aureus nasal carriage in patients with rhinosinusitis

Toxic shock syndrome has been associated with rhinologic surgery and medical devices, and it has been linked to a circulating exotoxin of a toxogenic strain of Staphylococcus aureus. One hundred forty patients with rhinosinusitis were studied. Nasal cultures were obtained. The microbiological characteristics are described. The carrier rate for Staphylococcus aureus was 35%. Thirty percent of patients selected for surgery were Staphylococcus aureus carriers. Toxin-capable isolates were identified in 40% of those tested. Users of cocaine, topical decongestants, and steroid sprays had a statistically higher rate of Staphylococcus aureus carriage compared to non-users. It is hoped that by identifying the population at risk and defining the factors associated with the development of toxic shock syndrome, a cogent policy of prevention can be established.     

Surgical management for mentosternal contractures by flap procedures

Mentosternal contractures still represent a surgical challenge due to their prominent position. They require early operative treatment for both function and aesthetic reasons. Careful clinical examination of scar position and traction forces, both at rest and when functioning, in addition to proper evaluation of the surrounding soft tissue are mandatory for precise preoperative planning of the required reconstruction. In general, the technically most feasible operation is favored if the functional and aesthetic results are good and postoperative risk for recurrence is low. Between 1987 and 1994, 21 patients with cervical, mentosternal, and mentothoracic contractures were operated upon. Eight patients were reconstructed with local flaps and 13 with microvascular free flaps.     

Influence of bile on the severity of acute experimental pancreatitis induced by closed duodenal loop in rat.

The study was performed to assess the ethiological role of bile in acute pancreatitis provoked by closed duodenal loop in rat. In group I a closed duodenal loop was created by method of Nevalainen. A similar operation was performed in group II, but the common pancreatico-biliary duct was ligated just under the liver. In the control group (group C) only the mobilization of duodenum was performed. After 24 hours the mortality rate was 20% in group I, but 0% in group II and C. The amount of ascitic fluid showed significant elevation in group I versus II and group C, and in group II as compared to group C, too. The serum amylase was significantly higher in group I than group II and group C, and in group II was also higher as compared to group C. Serum total protein differed significantly between all groups, while albumin and total calcium were significantly lower in group I than group II, but group II was only slightly reduced versus group C. Histology showed no differences between groups I and II, but both differed significantly from group C. In conclusion bile seems to be an aggressive factor in pathogenesis of acute pancreatitis induced by closed duodenal loop in rat, but other factors may play more important roles.