Abnormal sleep in patients with epileptic or dissociative (non-epileptic) seizures: a polysomnography study.

BACKGROUND AND PURPOSE: The aim of this study was to identify the prevalence of sleep disorders and measure the objective sleep quality in patients with seizure disorders. METHODS: Patients admitted for video electroencephalography monitoring were prospectively recruited and polysomnography was performed on the third night of monitoring. RESULTS: A total of 4/44 (9%) patients with epilepsy and 2/22 (9%) patients with dissociative seizures were found to have mild sleep-disordered breathing. Three (7%) patients with epilepsy were found to have mild or moderate obstructive sleep apnea-hypopnea syndrome (OSAHS) and three (14%) patients with dissociative seizures had mild or moderate OSAHS. Most patients with sleep-disordered breathing or OSAHS were overweight or obese. Time awake after sleep onset was high in both groups. There were no significant differences in sleep architecture between the groups except for a difference in average N3 sleep stage proportion. Periodic limb movements (PLMs) were common in both groups and 27% of patients with dissociative seizures had both high PLM rates and high arousal indices, suggesting a high prevalence of probable PLM disorder in that group (compared with 9% in the epilepsy group). CONCLUSIONS: Our findings contradict the commonly reported high comorbidity of OSAHS and epilepsy, and question its purported clinical relevance. High rates of PLMs were found in patients with dissociative seizures. In both patient groups, high awake after sleep onset times were indicative of sleep disruption, which can have an epileptogenic effect and is known to increase dissociative tendencies.

Syndrome and outcome of antibody-negative limbic encephalitis.

BACKGROUND AND PURPOSE: The aim was to report the clinical characteristics of 12 patients with limbic encephalitis (LE) who were antibody-negative after a comprehensive immunological study. METHODS: The clinical records of 163 patients with LE were reviewed. Immunohistochemistry on rat brain, cultured neurons and cell-based assays were used to identify neuronal autoantibodies. Patients were included if (i) there was adequate clinical, cerebrospinal fluid (CSF) and magnetic resonance imaging information to classify the syndrome as LE, (ii) magnetic resonance images were accessible for central review and (iii) serum and CSF were available and were confirmed negative for neuronal antibodies. RESULTS: Twelve (7%) of 163 LE patients [median age 62 years; range 40-79; 9 (75%) male] without neuronal autoantibodies were identified. The most frequent initial complaints were deficits in short-term memory leading to hospital admission in a few weeks (median time 2 weeks; range 0.5-12). In four patients the short-term memory dysfunction remained as an isolated symptom during the entire course of the disease. Seizures, drowsiness and psychiatric problems were unusual. Four patients had solid tumors (one lung, one esophagus, two metastatic cervical adenopathies of unknown primary tumor) and one chronic lymphocytic leukemia. CSF showed pleocytosis in seven (58%) with a median of 13 white blood cells/mm3 (range 9-25). Immunotherapy included corticosteroids, intravenous immunoglobulins and combinations of both drugs or with rituximab. Clinical improvement occurred in six (54%) of 11 assessable patients. CONCLUSIONS: Despite the discovery of new antibodies, 7% of LE patients remain seronegative. Antibody-negative LE is more frequent in older males and usually develops with predominant or isolated short-term memory loss. Despite the absence of antibodies, patients may have an underlying cancer and respond to immunotherapy.

[Clinical problems of surgical infection. The Pirogov Institute for Emergency Medicine, Sofia]. / Klinische Probleme der chirurgischen Sepsis. Republikanisch-wissenschaftlich-praktisches Institut für dringliche medizinische Hilfe "N.I. Pirogov" - Sofia.

The aetiology, pathogenesis, diagnosis and therapy of sepsis are dealt with in this paper. These problems are discussed on the basis of 151 patients treated for sepsis. The cases with monoinfection are 73.6% and those with polyinfection are 24.4%. Monoinfection is caused mainly by Staphylococci -65,3%, followed by E. coli - 15.2%, Proteus - 13% and Klebsiella - 3.3%. For the cases of polyinfection the gram-negative bacteria are 3:1 in respect to the gram-positive bacteria. The bacteriological finding from the haemoculture (92.8% mono- and 7.2% polyinfection) is not equal to this from the input source. Here also the cases of monoinfection are mainly caused by Staphylococci - 70.9%, followed by Proteus - 7.7%, E. coli - 6%, Klebsiella aerogenes - 5.1% and Streptococcus 2.6%. The gram-negative bacteria prevail in the cases of polyinfection. The virulent aggressive infection, bacteria resistant to antibiotics, the aggressive local infection, hypoproteinemia, anaemia, diabetes, a prolonged corticosteroid treatment and unsuitable antibiotic treatment are discussed as main factors predisposing to sepsis. All the 151 patients were treated with the complex therapy, recommended in this paper. It includes a surgical cleaning-up of the initial nidus, intensive reasonable antibiotic treatment against the gram-positive and gram-negative aerobes and anaerobes. Additionally, substitution of infusion therapy, parenteral nutrition, regulation of the pathophysiological deviations and stimulating therapy are carried out. 74.2% from the patients were cured, 25.8% died. 16.6% of the patients who died had sepsis caused by gram-positive bacteria, and 46.1% had sepsis caused by gram-negative bacteria. 17% of the patients who died had septicaemia and 22% had septicopyaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bone transplantation in the treatment of haematogenous and posttraumatic osteomyelitis (author's transl)]. / Die Knochentransplantation bei der Behandlung der hämatogenen und der posttraumatischen Osteomyelitis.

The author presents 602 patients--436 with haematogenous osteomyelitis and 166 with posttraumatic suppurative osteitis. The clinical material is analysed according to the following criteria: age, localization, morphology, kind of infection, operative methods. The author recommends bone replacement ot the donor area with allogenous cancellous bone. No complications were observed in 285 operations of this kind. The osteoplastic treatment of haematogenous osteomyelitis provides healing 86% and of posttraumatic suppurative osteitis--in 79% of the cases. Thanks to reoperations, this percentage increases to 97% for the haematogenous osteomyelitis and to 98% for posttraumatic purulent osteitis respectively.

[Refilling of bone defects after taking out of bone transplants (author's transl)]. / Entnahme autologer Knochentransplantate und gleichzeitiger osteoplastischer Ersatz des Donorknochendefektes.

The author recommends to refill the donor defect by preserved allogeneic cancellous bone chips. In this way much more autogenous material for grafting can be gained. At the site of the taking out a restitutio ad integrum will take place. This procedure has been practised in 387 donor bone defects. Technical details and results are dealt with.

[Bone grafting in the treatment of hematogenic osteomyelitis]. / Kostno prisazhdane za lechenieto na khematogenniia osteomielit.

A qualitatively new method is introduced, developed and established in practice on the ground of clinical experience with 44 patients with hematogenic osteomyelitis. Thus the idea about "osteoplastic treatment of osteomyelitis" is adopted. Bone transplantation is the basic and dynamic factor of this type of management. Contrary to traditional concepts the author's clinical experience shows that successful bone grafting is possible provided all specific requirements are met, namely radical removal of the purulent-necrotic substrate, presence of regeneration potential in the recipient bed, creation of favourable conditions for wound healing by first intention, and active struggle against infection as a permanently acting factor, and in case it is already present. The bone transplant in addition to promoting elimination of the osteomyelitic bone defect, which is the primary pathogenic factor of chronic pus discharge, contributes also to the cure of the basic process in the course of its dynamic interaction with the recipient bone. Bone auto-, allo- and xeno (calf)-grafts are used as transplantation material. The indications for osteoplastic treatment, the surgical policy, operative technique and operative procedures are presented. The proposed original operative methods of osteoplastic management are submitted schematically and illustrated by single case reports. Complete cure as the result of osteoplastic treatment alone is attained in 388 cases or 87.3 per cent out of the total number of 444 patients. In the remaining 55 cases in whom the treatment failed, reoperation was performed because of residual foci, complications on behalf of the graft (sequestration), persistent fistulae or skin defects, resulting in the cure of fifty of them. Here too, the attained result is attributable to the osteoplastic treatment. Hence out of the total number of 444 patients operated on a cure is achieved in 434 cases or 97.7 per cent. After comparative evaluation of the quality of bone graft a net preference is given to cancellous autografts. A transplant taken from the iliac crest is considered as the optimal quality one. Regarding massive bone grafts, auto- or allogenous alike, a rather elevated sequestration rate is recorded, 10 and 33 per cent respectively. A particular importance is ascribed to the regenerative qualities of the recipient bed. Results recorded among children are superior. In patients free of fistulae the rate of cures is 19.3 per cent higher in patients with fistulae.

[Current problems in hospital infection]. / Gegenwärtige Probleme des Hospitalismus.

(1) In surgical infections staphylococci are still dominating. (2) Following nosocomial infections gramnegative pathogens become more and more important. (3) Systemic administration of antibiotics favour the selection of gramnegative bacteria and the increase of resistence. (4) Antibiotics do not substitute asepsis and antisepsis. (5) The systemic administration of antibiotics in surgical infections should be clearly reduced. (6) No prophylactic use of antibiotics in surgery to prevent wounds infections.

[Clinical importance of the immunoserological data on the bone allotransplantation (author's transl)]. / Die klinische Bedeutung der immunoserologischen Befunde bei der Transplantation von Alloknochen

The clinical and immunoserological data in 66 bone grafted patients are analysed. The importance of the immunological histocompatibility in bone allotransplantation is discussed in a short introduction. The method of transplantation is given and the clinical material is analysed in 3 tables. It is clear from the discussion, that in 6 out 66 patients there are data for an isoimmunization in result of the transplantation. Cytotoxins in the patients' sera are demonstrated after transplantation of frozen grafts. No HL-A antibodies are demonstrated following transplantation of bone grafts, treated after the method of Maatz and Bauermeister. The humoral antibodies are of a greater importance in transplantation of larger bone grafts, as well as of bone-joints complexes. It is acceptable that the immune conflict is of importance as regards to the pathological resorption of the graft. Often, the histocompatibility is a basical reason for the suppuration and sequestration of the graft. The antigenicity of the graft possesses an inductive action concerning the new bone formation. The importance of the osteogenic possibility of the bone-bed-recipient is underlined. It is desirable for a modern tissue bank to be able to offer bone grafts with determined specificity concerning ABO, Rhesus-D and HL-A systems. This will be a new perspective in the bone allotransplantation.