Alternative component containing diesel fuel from different waste sources.

Mixtures with high fatty acid content are produced during vegetable oil and animal fat purification and paper production. These waste fractions can be converted into alternative fuels through several steps. The co-hydrogenation of waste polypropylene thermal cracked fraction or waste fatty acid mixture with unrefined gas oils is a potential solution for their conversion into hydrocarbons. The co-processing of these three different fractions was not yet investigated in these ratios. So the aim of the research work was to produce high quality diesel fuels and to study the occurring reactions and the interaction among these different compounds. The catalytic conversion of the mixture of unrefined gas oil, waste polypropylene cracked fraction (20 wt %) and waste fatty acid mixture (10, 20 and 30 wt %) was carried out on a commercial sulphided nickel-molybdenum-alumina catalyst. The effect of the feedstock compositions and the process parameters on the quantity and quality of the products was studied. The favourable process conditions to produce high quality diesel fuel blending components were selected (e.g., 10 wt % fatty acid waste, 360 °C temperature, 1.0 h-1 liquid hourly space velocity). The performance properties of this fuel were better than the conventional diesels', so their usage can be more environmentally friendly and lead to lower pollutant emission.

Postoperative interictal spikes during sleep contralateral to the operated side is associated with unfavourable surgical outcome in patients with preoperative bitemporal spikes.

PURPOSE: To correlate the persistence of contralateral spikes during sleep after unilateral surgery with seizure outcome in a temporal lobe epilepsy (TLE) population and to test the existing hypotheses about the origin of the contralateral spikes in temporal lobe epilepsy. METHODS: In the 19 patients selected for this study unilateral temporal lobe surgery was performed. To investigate the course of bilateral interictal epileptiform discharges observed before surgery in awake or sleep over the temporal lobe contralateral to surgery, 24 h mobile 12 channel EEG recording was performed at minimum two, in average 4.6 (2-10) years after the surgery. RESULTS: The association of postoperative contralateral spikes and non-seizure free outcome was highly significant. The existence of unilateral pathology before surgery was highly predictive for good outcome and disappearance of contralateral spikes. The association between good seizure outcome, disappearance of contralateral spikes and the existence of unilateral pathology before surgery was also significant. Our data partially satisfies the expectations of both the "seizure induced" and mirror type secondary epileptogenesis hypotheses concerning origin of contralateral spikes, but were not completely congruent with either of them. CONCLUSIONS: Unfavourable surgical outcome in a temporal lobe epilepsy group with preoperative independent bilateral interictal spikes was associated with the persistence of postoperative contralateral spikes and lack of unilateral pathology. Compared with seizure outcome the presence/absence and distribution of postoperative interictal spikes in NREM sleep not entirely fit to the predictions of existing secondary epileptogenesis hypotheses.

Orgasmic aura--a report of seven cases.

We report on seven patients who experienced an orgasmic aura at the start of their seizures. The patients (five women, two men) were aged 36-58. Three of seven patients described the exact nature of their auras only many years after their appearance, when the epilepsy diagnostic procedure became more intensive due to drug resistance. Moreover, one patient even refused any new therapeutical options due to the reportedly positive role of the orgasmic aura in her life. All of our patients had temporal lobe epilepsy. The clinical picture, EEG, MRI or SPECT findings suggested a right temporal epileptic focus in six patients, while in one patient the epileptogenic region was localised in the left temporal lobe. In the latter case, the left hemisphere was speech-dominant, while in the other cases no Wada tests were done. Our results confirm that orgasmic aura could be considered as an ictal lateralising sign to the right hemisphere, however, it has no 100% lateralising value.

Intentional seizure interruption may decrease the seizure frequency in drug-resistant temporal lobe epilepsy.

We investigated the nature of preictal subjective phenomena and whether they had any effect on the seizure frequency in 95 adult patients with medial temporal lobe epilepsy. Seventy-three (77%) patients indicated that they experienced seizure-provoking factors. Ten patients (11%) had prodromas independent of auras, while auras occurred in 89%. Forty-four patients (46%) reported that that they had tried to stop their seizures in the presence of prodroma or aura and this action had resulted in success at least once. Twenty-one patients (22%) regularly tried to stop their seizures because this effort was often successful according to their interpretation. Patients who reported that they could frequently inhibit their seizures had 1.8 +/- 1.6 seizures/month, a significantly lower mean seizure frequency than those 74 patients who did not do it regularly (4.6 +/- 4.8 seizures/month, P<0.001). Patients who reported regular experience in inhibiting intentionally their seizures more often had affective (P=0.05) and vertiginous auras (P<0.01) as well as isolated auras (P<0.05). Patients who experienced provoking factors showed the same seizure frequency as those who did not. Our results suggest that intentional seizure inhibition had an impact on the severity of drug-resistant epilepsy.

Misleading hallucinations in unrecognized narcolepsy.

OBJECTIVE: To describe psychosis-like hallucinatory states in unrecognized narcolepsy. METHOD: Two patients with hypnagogic/hypnapompic hallucinations are presented. RESULTS: Both patients had realistic and complex - multi-modal and scenic-daytime sexual hallucinations leading, in the first case, to a legal procedure because of false accusation, and in the second, to serious workplace conflicts. Both patients were convinced of the reality of their hallucinatory experiences but later both were able to recognize their hallucinatory character. Clinical data, a multiple sleep latency test, polysomnography, and HLA typing revealed that both patients suffered from narcolepsy. CONCLUSION: We suggest that in unrecognized narcolepsy with daytime hypnagogic/hypnapompic hallucinations the diagnostic procedure may mistakenly incline towards delusional psychoses. Daytime realistic hypnagogic/hypnapompic hallucinations may also have forensic consequences and mislead legal evaluation. Useful clinical features in differentiating narcolepsy from psychoses are: the presence of other narcoleptic symptoms, features of hallucinations, and response to adequate medication.

Automatisms with preserved responsiveness and ictal aphasia: contradictory lateralising signs during a dominant temporal lobe seizure.

The 25-year-old right-handed woman suffering from temporal lobe epilepsy (TLE) was referred to our centre for presurgical evaluation. MRI showed a right-sided hippocampal sclerosis. During video-EEG-recorded seizures, abdominal aura was followed by oral automatisms, during which she was completely reactive to external stimuli, although she was unable to speak. Ictal EEG showed right temporal seizure pattern, without contralateral propagation. She had abnormal speech postictally. Speech-activated functional transcranial Doppler sonography revealed right-sided speech dominance. She has become seizure free after a right-sided amygdalo-hippocampectomy. In our patient, contradictory clinical ictal lateralising signs (automatisms with preserved responsiveness vs. ictal and postictal dysphasia) occurred during right-, speech-dominant-sided seizures. This is the first report when automatisms with preserved consciousness occurred during a seizure originating and involving the speech-dominant hemisphere.

Ictal SPECT in children with epilepsy: comparison with intracranial EEG and relation to postsurgical outcome.

In order to validate the ability of ictal single photon emission computed tomography (SPECT) to localize the epileptogenic zone (EZ) in children, we compared in 20 patients aged from 10 months to 17 years (mean 6.5 years) the topography of the area of increased ictal perfusion (IPA), determined on the basis of ictal minus interictal scan values, with that of the EZ determined by intracranial EEG recordings and assessed its relationship with the postsurgical outcome. Eighteen patients had symptomatic epilepsy and 10 had extratemporal epilepsy. All patients except one had an ictal injection (mean time lag from clinical seizure onset was 18 s). Ictal and interictal SPECT images were successively co-registered, normalized, subtracted, smoothed and superimposed on MRI. All patients with ictal injection exhibited one or several IPAs. The topography of the 'highest' IPA, i.e. the maximal cerebral blood flow (CBF) change between ictal and interictal SPECT, significantly colocalized with the site of onset of the discharge, and that of the lower IPAs with that of the area of propagation (P < 0.0001). At a threshold of 30% of the maximal CBF change, the IPAs detected the onset of the discharge with a sensitivity of 0.80 and a specificity of 0.70. The highest IPA localized the EZ in 12 out of 15 patients. In the three others it missed the EZ and showed the area of propagation because of rapid seizure propagation or of infraclinical seizure onset. Among the patients with favourable surgery outcome, the highest IPA colocalized with the resected area in 70% of cases. Ictal SPECT could therefore plays an important role as a non-invasive presurgical method of investigation by optimizing the placement of intracranial electrodes, thus improving the postsurgery outcome of paediatric partial epilepsy.

Misleading lateralization by ictal SPECT in temporal lobe epilepsy-- a case report.

A 28-year-old woman with temporal lobe epilepsy underwent presurgical evaluation. Scalp-EEG showed non-localizing seizure patterns. MRI revealed a right hippocampal sclerosis. Ictal HMPAO-SPECT showed a marked left temporal hyperperfusion. Video-EEG monitoring with foramen ovale electrodes (FOE) showed an initial seizure pattern which appeared in the right FOE and which shifted to the left 8 s after clinical onset. Three years after a right temporal lobectomy, the patient is seizure-free. In conclusion, although the ictal SPECT suggested a left temporal seizure focus, the intracranial EEG and the postoperative seizure-freedom confirmed the right-sidelocation of the epileptogenic region. A rapid right-left seizure spread explains the mechanism of falsely lateralizing ictal SPECT.

Orgasmic aura originates from the right hemisphere.

The authors present a patient with right mesiotemporal epileptogenic region who experienced orgasmic epileptic aura. Twenty-two similar published cases were also evaluated. Among 15 patients with unilateral EEG foci, 13 (87%) had right and 2 (13%) had left focus. All of the nine patients who had sufficient data on ictal onset area had right-sided seizure onset. The authors suggest that orgasmic aura is an ictal lateralizing sign to the right hemisphere.

[Treatment and long-term follow-up of post-anoxic myoclonus]. / Postanoxiás myoclonus kezelése és hosszú távú követése.

UNLABELLED: Postanoxic myoclonic (Lance-Adams) syndrome is characterized by myoclonic jerking provoked by intention or external stimuli. The authors present a patient in whom high-dose piracetam treatment resulted in a long-term improvement. Their female patient jumped into the river in order to commit a suicide. She was rescued in the state of clinical death. After a successful reanimation, she was comatose for 16 days. Despite the adequate rehabilitation therapy, her movement status did not change, due to jerking induced by external stimuli. Two months after the asphyxia, the patient was still confined to bed. The authors diagnosed her illness as Lance-Adams syndrome, based on the clinical history and symptoms. Valproic acid and clonazepam was introduced and, after a few days 24 g piracetam was added intravenously. After the first piracetam infusion, the jerking dramatically diminished, she was able to walk with some help. During the 4-years follow up, she received orally 19.2 g piracetam, 1500 mg valproic acid and 6 mg clonazepam. Now she is able to walk without help for a short distance and her cognitive functions have almost completely restituted. CONCLUSION: Lance-Adams syndrome is usually recognized only in a late phase, preventing the early rehabilitation. The trias consisting of anoxia, coma, and stimulus-sensitive myoclonus, however, can be easily recognized, and the adequate treatment may lead to a significant improvement.

Functional imaging in the work-up of childhood epilepsy.

In children with medically intractable lesional epilepsy, surgery is deemed successful if the epileptogenic focus can be removed while major neurological functions are spared. Current techniques rely on invasive intracranial recordings. The new developments in functional imaging offer the possibility of localizing the epileptogenic focus noninvasively (PET/SPECT) and mapping cognitive functions (fMRI). Ictal SPECT shows hyperperfusion in the focus and has proved to have better localizing value than interictal PET or SPECT, which show focal hypometabolism or hypoperfusion. Ictal SPECT is useful for deciding on the placement of intracranial electrodes in extratemporal epilepsies, particularly in young children. Functional MRI has proved highly accurate for localizing motor and language networks, thus offering the possibilities of replacing the Wada test (language hemispheric lateralization) and studying postlesional brain plasticity. Despite the difficulties of functional imaging in children owing to the limited cooperation that can be expected, ethical constraints, and poor normative data, SPECT/PET and fMRI provide clinically useful information for presurgical work-up of childhood epilepsies.

Ictal perfusion changes during occipital lobe seizures in infancy: report of two serial ictal observations.

Serial-ictal single-photon-emission computed tomography (SPECT) examinations are presented in two infants (ages 1 and 2 years), with early ictal and ictal in one, and ictal and late ictal images in the other. Both had pharmacoresistant occipital epilepsy, due to focal cortical dysplasia. In the first case, size of ictal hyperperfusion increased in the course of the seizure from early ictal to ictal state. A concomitant ictal hypoperfusion was observed around the hyperperfused area. In the second patient, there was a dramatic difference between ictal and late ictal images. In the late ictal state, the previous occipital ictal hyperperfusion and extraoccipital ictal hypoperfusion disappeared, together with homolateral posterotemporal and contralateral occipital hyperperfusion, corresponding to seizure propagation. Ictal extratemporal blood-flow changes are therefore highly dynamic, particularly in very young children.

[Ictal SPECT in the epileptic child. Contribution of subtraction interictal images and superposition of with MRI]. / SPECT ictal chez l'enfant épileptique. Intérêt de la soustraction avec les images interictales et de la superposition avec l'IRM.

Ictal SPECT is a highly sensitive method to localize the epileptogenic focus in refractory temporal lobe epilepsy in adults. In extratemporal epilepsy, sensitivity can be improved by subtracting interictal from ictal images and superimposing subtraction images on MRI. In children, such a procedure is potentially interesting because most epilepsies are extratemporal and ictal SPECT not yet routinely developed. The aim of this study was to test the feasibility of ictal SPECT with subtraction image processing in a pediatric population. Twenty-six children with refractory partial epilepsy and aged from 3 months to 18 years underwent ictal ECD-SPECT (20 mCi/1.73 m2) combined with video-EEG and interictal ECD-SPECT plus 3D-MRI two days later. Ictal-interictal subtraction images were computed by registering and normalizing the ictal to the interictal SPECT scans for each child. The ictal, interictal SPECT and subtraction images were registered to the children's MRI. Difference images were then superimposed to MRI for anatomical localization of the perfusion changes (overlay images). Looking for perfusion changes, overlay images allowed to detect at least one hyperperfused focus in 92 p. 100 of the 26 children compared to 73 p. 100 visually comparing ictal and interictal scans separately. Seizure onset was suspected on clinical and/or EEG and/or MRI in 19 children. Positive overlay images were concordant (n = 11) or larger (n = 7) than the suspected focus in 17/19 (90 p. 100), whereas they failed to show any abnormality in 1 child and were discordant with MRI in another one. In the 7 remaining patients, images showed cortical localization in 6 cases. Ictal SPECT is therefore faisable in very young children. Ictal-interictal subtraction SPECT images co-registered to MRI improves sensitivity compared to classical visual analysis. It seems therefore to be a helpful technique to localize the onset of seizure and to guide the intracranial recording in childhood epilepsy.

Use of subtraction ictal SPECT co-registered to MRI for optimizing the localization of seizure foci in children.

UNLABELLED: Ictal SPECT studies are increasingly used to localize seizure foci in children with refractory epilepsy, but few studies have reported on ictal-interictal subtraction images co-registered to MRI at this age. METHODS: Twenty-seven children with partial epilepsy (aged 3 mo-18 y) underwent ictal ethyl cysteinate dimer (ECD) SPECT (20 mCi/1.73 m2) combined with video-electroencephalography (EEG) and interictal ECD SPECT followed 2 d later by three-dimensional MRI. Ictal-interictal and interictal-ictal subtraction images were computed by registering and normalizing the ictal to the interictal SPECT scans for each child. The ictal, interictal SPECT and subtraction images were registered to each child's MRI. Difference images (ictal-interictal) were then superimposed on MRI for anatomic localization of the perfusion changes. Intra- and interobserver reproducibility and "facility of interpretation" of overlay images were compared with standard analysis of the non-coregistered ictal and interictal scans. RESULTS: Overlay images allowed the detection of at least one hyperperfused focus in 93% of the children, compared with 74% using ictal and interictal scans separately. Seizure onset was suspected clinically, on EEG or on MRI in 20 children. Overlay images were concordant (n = 11) or larger (n = 7) than the suspected focus in 18 of 20 (90%), whereas these images failed to show any abnormality in 1 child and were discordant with MRI in another patient. In the remaining 7, images showed cortical localization in 6 patients. Among the 5 patients who underwent electrocorticography, overlay images were concordant in 3, larger in 1 and absent in 1. The intra- and interobserver reproducibility and facility of interpretation were significantly higher using overlay images than standard analysis, even when ictal and interictal SPECT were co-registered. CONCLUSION: The co-registration of ictal-interictal subtraction SPECT images to MRI seems to be a helpful technique in localizing the onset of seizure and guiding the intracranial recording in childhood epilepsy. Moreover, this method improves sensitivity, enhances intra- and interobserver reproducibility and makes interpretation easier.

What health professionals can do to identify and resolve patient dissatisfaction.

BACKGROUND: Patient satisfaction affects consistency of self-care, health outcomes, level of service utilization, choice of health professionals, and decisions to sue in the face of adverse outcomes. Understanding patients' specific dissatisfactions may help health professionals and administrators identify and rectify organizational deficiencies before they become costly. COMMON CAUSES OF COMPLAINTS: As part of a series of research projects, more than 12,000 patient/family complaint narratives were examined in which patients or patients' family members told interviewers or patient advocates about the care they received from their health professionals in both inpatient and outpatient settings. Complaints may be categorized as involving issues of care and treatment, communication, humaneness, access and availability, environment, and billing/payment. STRATEGIES FOR RESOLVING COMPLAINTS: Even though caregivers may not have control over all the factors that lead to dissatisfaction, they can often hear and address complaints. As a result, they may not only contribute to quality of care but improve the systems in which they practice. The challenges are how to prevent dissatisfaction in the first place, and, if it does occur, to identify and if possible rectify patient concerns. Three case studies are provided. CONCLUSION: All health professionals must be involved in efforts to resolve problems that compromise patient care. Some problems could be prevented if administrators and leaders used complaint data to recommend new policies and procedures or to identify and counsel with health care team members who generate disproportionate numbers of complaints. If all are involved in both prevention and problem solving, resources devoted to uncovering, understanding, and resolving patient complaints are likely to prove cost-effective.

[First Hungarian experiences with positron emission tomography (PET) studies. Members of the PET working group]. / Elsö hazai tapasztalatok pozitron emissziós tomográfiás (PET) vizsgálatokkal. PET munkacsoport tagjai.

Diagnostic investigations commenced on the 28th of June 1994 in Hungary's and Central Europe's first PET Centre at the University Medical School of Debrecen. The Centre is equipped with a GE 4096 Plus whole body PET scanner. A metabolic tracer, 18F-deoxy-D-glucose (FDG), was used in the investigations. During the first 15 months 249 PET investigations were made in the Centre of which 242 were diagnostic and 7 normal subjects served as control for the patient studies with brain scans. The number of oncological indications (intra- and extracranial tumours, Hodgkin's lymphomas) was n = 105 (43.4% of the 242 diagnostic examinations), neurological investigations (without intracranial tumours) formed the dominant group (n = 117; 48.3%), whereas the number of cardiological indications was 20 (8.3%). The oncological studies included those of intracranial tumours (n = 76; 31.4%); thyroid tumours (n = 9; 3.7%); Hodgkin's lymphomas (n = 7; 2.9%) and other extracranial tumours (n = 13; 5.4%). The distribution of different neurological and psychiatric investigations was as follows: localization of focal epileptogen zone (n = 60; 24.8%); differential diagnosis of dementias (n = 30; 12.4%); exploration of cerebrovascular diseases (n = 10; 4.1%); and other neurological diseases (n = 17; 7.0%). The main objective of the cardiological PET investigations was the exploration of viable myocardium. The present paper overviews both the procedures (including administrative issues, as well) and the results of the first 249 FDG-PET investigations.