Psychogenic seizures: long-term outcome in patients with and without epilepsy.

OBJECTIVES: Psychogenic non-epileptic seizures (PNES) may resemble epileptic events. Epileptic and non-epileptic seizures are not mutually exclusive phenomena and may coexist in the same patient. The aim of this study was to evaluate the long-term outcome of psychogenic events in patients with PNES alone and those with both PNES and epilepsy (PNES + EPI) as diagnosed by video-EEG (vEEG) monitoring. MATERIALS AND METHODS: All adult admissions to the Tel-Aviv Medical Center's vEEG unit between 2004 and 2009 were screened for the presence of PNES. We retrospectively retrieved data from their medical files and supplemented the follow-up by a telephonic questionnaire. RESULTS: Eligible patients (n = 51) were divided into those with PNES + EPI (n = 24) and those with PNES alone (n = 27). The follow-up period was 4.8 ± 0.3 and 4.3 ± 0.3 years, respectively. Both groups had similar female predominance and similar age at admission to the vEEG unit. Time from PNES onset to hospitalization was longer in PNES patients compared to those with PNES + EPI. The majority of subjects in each group reported a history of at least one major stressful life event. Opisthotonus was significantly more frequently observed in PNES patients, and they had more events during vEEG hospitalization. Psychogenic events ceased during the follow-up period in 22% of the PNES patients and in 58% of the PNES + EPI patients (P > 0.001). CONCLUSION: Our results indicate that following vEEG-based diagnosis of PNES, the long-term outcome of PNES cessation may be more favorable for patients with concomitant epilepsy than for patients without epilepsy.

Mesenchymal stem cells induced to secrete neurotrophic factors attenuate quinolinic acid toxicity: a potential therapy for Huntington's disease.

Huntington's disease (HD) is a hereditary, progressive and ultimately fatal neurodegenerative disorder. Excitotoxicity and reduced availability of neurotrophic factors (NTFs) likely play roles in HD pathogenesis. Recently we developed a protocol that induces adult human bone marrow derived mesenchymal stem cells (MSCs) into becoming NTF secreting cells (NTF(+) cells). Striatal transplantation of such cells represents a promising autologous therapeutic approach whereby NTFs are delivered to damaged areas. Here, the efficacy of NTF(+) cells was evaluated using the quinolinic acid (QA) rat model for excitotoxicity. We show that NTF(+) cells transplanted into rat brains after QA injection survive transplantation (19% after 6 weeks), maintain their NTF secreting phenotype and significantly reduce striatal volume changes associated with QA lesions. Moreover, QA-injected rats treated with NTF(+) cells exhibit improved behavior; namely, perform 80% fewer apomorphine induced rotations than PBS-treated QA-injected rats. Importantly, we found that MSCs derived from HD patients can be induced to become NTF(+) cells and exert efficacious effects similarly to NTF(+) cells derived from healthy donors. To our knowledge, this is the first study to take adult bone marrow derived mesenchymal stem cells from patients with an inherited disease, transplant them into an animal model and evidence therapeutic benefit. Using MRI we demonstrate in vivo that PBS-treated QA-injected striatae exhibit increasing T(2) values over time in lesioned regions, whereas T(2) values decrease in equivalent regions of QA-injected rats treated with NTF(+) cells. We conclude that NTF cellular treatment could serve as a novel therapy for managing HD.

Placenta-bound and body fluid PP13 and its mRNA in normal pregnancy compared to preeclampsia, HELLP and preterm delivery.

OBJECTIVES: To compare the distribution of placental protein 13 (PP13) in fetal and maternal blood and amnionic fluid and to correlate it with PP13 protein and mRNA in the placenta. METHODS: Umbilical arterial serum, amnionic fluid, maternal venous serum and placental tissues were collected from normal outcome pregnancies (N = 63) (GA>37), early onset preeclampsia (PE) (N = 12, GA: 26-33), and HELLP syndrome (N = 5, GA: 27-29). Because PE and HELLP cases delivered preterm, cases of preterm delivery (PTD) (N = 6, GA: 31-36) served as additional control. PP13 was determined by ELISA, Western blot, and immunohistochemistry. PP13 mRNA was measured by PCR (RT-PCR). Continuous parameters were compared by t-test, P < 0.05 was considered significant. RESULTS: In women with normal pregnancy outcome significantly higher PP13 levels were found in maternal serum compared to amnionic fluid and negligible amount was found in fetal serum. A similar pattern was identified in cases of PTD with concentrations similar to term control. In PE and HELLP cases PP13 levels in amnionic fluid level were more than twice compared to maternal serum (P < 0.001). Umbilical cord level was negligible in PE but high in HELLP corresponding to the much higher level of PP13 in this patient group compared to all others. In the placenta PP13 level in term controls was higher compared to PTD. In PE and HELLP (similar early delivery time as PTD) the level was significantly higher (P < 0.01) compared to PTD or term controls. PP13 mRNA levels in term control and PTD were similar while PP13 mRNA levels in PE and HELLP placentas were significantly lower compared to term controls or PTD or the two combined. Syncytiotrophoblast labeling appeared stronger in PE and HELLP compared to term controls and PTD. CONCLUSIONS: In all cases but HELLP, PP13 in fetal blood is very low indicating that routing of PP13 to fetal blood is limited and that the fetus is unlikely to generate PP13. PP13 mRNA is lower in the third trimester at the time of disease while protein level accumulates and become higher creating an unparallel change in the level of the mRNA and the corresponding protein.

Intracerebral adult stem cells transplantation increases brain-derived neurotrophic factor levels and protects against phencyclidine-induced social deficit in mice.

Stem cell-based regenerative therapy is considered a promising cellular therapeutic approach for the patients with incurable brain diseases. Mesenchymal stem cells (MSCs) represent an attractive cell source for regenerative medicine strategies for the treatment of the diseased brain. Previous studies have shown that these cells improve behavioral deficits in animal models of neurological disorders such as Parkinson's and Huntington's diseases. In the current study, we examined the capability of intracerebral human MSCs transplantation (medial pre-frontal cortex) to prevent the social impairment displayed by mice after withdrawal from daily phencyclidine (PCP) administration (10 mg kg(-1) daily for 14 days). Our results show that MSCs transplantation significantly prevented the PCP-induced social deficit, as assessed by the social preference test. In contrast, the PCP-induced social impairment was not modified by daily clozapine treatment. Tissue analysis revealed that the human MSCs survived in the mouse brain throughout the course of the experiment (23 days). Significantly increased cortical brain-derived neurotrophic factor levels were observed in the MSCs-treated group as compared with sham-operated controls. Furthermore, western blot analysis revealed that the ratio of phosphorylated Akt to Akt was significantly elevated in the MSCs-treated mice compared with the sham controls. Our results demonstrate that intracerebral transplantation of MSCs is beneficial in attenuating the social deficits induced by sub-chronic PCP administration. We suggest a novel therapeutic approach for the treatment of schizophrenia-like negative symptoms in animal models of the disorder.

Fasting does not precipitate onset of labour.

This retrospective observational study examined whether fasting (the 'Yom Kippur effect') precipitates labour. Birth rates of Yom Kippur (a fasting festival) were compared with those of other festivals that are observed (Tisha B'Av) and not observed (1st day of Passover) by fasting during a 4-year period. Compared with the mean birth rate, the number of births that occurred 1 day after Yom Kippur was increased (p = 0.023). A significant decrease in the number of births during Tisha B'Av (p = 0.044) and a significant increase in the number of births 2 days after Tisha B'Av (p = 0.009) was observed. Two days prior to the 1st day of Passover, a significant decrease in the number of births was also observed (p = 0.034). Contrary to previous reports, the present study does not confirm an association between a 1-day long fast and increased birth rate in the 24-h period after breaking of the fast.

Sonographic characteristics of the uterine cavity following first-trimester uterine evacuation.

OBJECTIVE: To characterize the sonographic appearance of the uterine cavity after first-trimester uterine evacuation and to follow the evolution of these findings in an attempt to reduce the number of unnecessary surgical interventions following evacuation. METHODS: We studied retrospectively the sonographic characteristics of the uterine cavity in 599 women, 5-8 days after first-trimester uterine evacuation. The patients were grouped according to the sonographic appearance of the uterine cavity. Patients with abnormal sonographic patterns were followed weekly until sonographic resolution. RESULTS: Group 1 included 351 (58.6%) women with normal endometrium; Group 2 included 130 (21.7%) women with hypoechoic endometrial content only; Group 3 included 69 (11.5%) patients with mixed type (hypoechoic and hyperechoic) endometrial content; Group 4 included 49 (8.2%) patients with hyperechoic endometrial content only. The time needed until the uterine cavity was considered normal was significantly longer in Group 4 (median, 12 days) compared with Groups 3 and 2 (8 and 9 days, respectively, P < 0.0001). The duration of vaginal bleeding after the surgical procedure was longer in Group 4 (median, 10 days) compared with Groups 3, 2 and 1 (9, 7 and 5 days, respectively, P < 0.0001). Clinically, the patients were divided into two groups: asymptomatic (575 patients) and symptomatic (24 patients). The thickness of the abnormal endometrial content in the asymptomatic patients gradually decreased until normalization, around the time of menstruation. There was no such change in the symptomatic patients, who eventually needed surgical intervention. CONCLUSIONS: An abnormal intrauterine sonographic pattern 5-8 days following first-trimester uterine evacuation is common and usually resolves spontaneously around menses. Therefore, in asymptomatic patients, we recommend a conservative approach.

Favorable outcome following emergency second trimester cerclage.

BACKGROUND: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. METHODS: A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. RESULTS: Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2). CONCLUSIONS: Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.

Patient-controlled epidural analgesia: the role of epidural fentanyl in peripartum urinary retention.

BACKGROUND: Urinary bladder function is impaired during labor and delivery, predisposing to urinary retention. The effect of low-dose epidural opioid on bladder function remains unclear. We tested the hypothesis that adding low-dose fentanyl to epidural ropivacaine for patient-controlled labor analgesia does not promote urinary retention. METHODS: Laboring women who requested patient-controlled epidural analgesia were randomly assigned in a double blind study to 0.2% ropivacaine (R-group, n=100) or 0.2% ropivacaine with fentanyl 2 microg/mL (RF-group, n=98). Urinary bladder distension was assessed clinically every hour. The post-void residual urine volume was measured by ultrasonography. Urine volume exceeding 100 mL was drained by catheterization. Bladder volume of > or =300 mL, as determined by catheterization was considered as evidence of urinary retention. RESULTS: Thirty percent of the patients in each group developed urinary retention during labor. There was no statistically significant difference between the groups. There was an excellent correlation between bladder volume as estimated by ultrasonography and that by catheterization: catheterization volume=0.93 x ultrasound volume + 25; r(2)=0.83. The bias (mean error) was -1+/-99 mL and the precision (average absolute error) between the ultrasound estimate and actual bladder volume determined by catheterization was 58+/-79 mL. CONCLUSION: Addition of fentanyl to patient-controlled epidural analgesia did not increase the risk of urinary retention. Ultrasound measurements were effective and reliable in assessing urinary bladder volumes during labor.

Vacuum extraction and herpes simplex virus infection.

OBJECTIVE: To search for an association between delivery by vacuum extraction and an increased neonatal risk for herpes simplex virus (HSV) infection. METHODS: In a cross-sectional, descriptive, controlled study, the study (vacuum extraction) and control (spontaneous delivery) groups each included 50 consecutive women with no history of HSV infection. Cultures for HSV were obtained from the genital tracts of all parturient women and the scalps of their newborns. RESULTS: Following operative vaginal delivery, two newborns (4%) had scalp vesicles and cultures were positive for HSV for both mothers and newborns; two newborns (4%) had scalp vesicles and cultures were negative for HSV; and two newborns (4%) without scalp vesicles had cultures positive for HSV. Following spontaneous delivery, cultures were positive for HSV for four women and their newborns (8%). CONCLUSION: Herpes simplex virus isolated from the scalps of newborns may often result from colonization rather than infection.

Relationship between uterine contractions and serum magnesium levels in patients treated for threatened preterm labour with intravenous magnesium sulphate.

We aimed to correlate the assessment of preterm uterine activity with serum magnesium levels in women with threatened preterm labour. The observational study involved twelve women receiving intravenous magnesium sulphate for threatened preterm labour. Mean gestational age at initiation of therapy was 26.9+/-2.9 weeks. Mean cervical dilatation at initiation of therapy was 1.5 cm. Serum magnesium levels and evaluation of uterine contractions by external tocograph were assessed twice daily. Presence or absence of contractions was analysed for correlation with plasma magnesium levels. Eighty-eight measurements were analysed. The mean serum magnesium levels were 1.9+/-0.5 mmol/l and 1.9+/-0.3 mmol/l in the presence (n=22) or absence (n=66) of contractions, respectively. The difference did not reach statistical significance. No correlation was found between serum magnesium levels and presence of contractions (P=0.3, logistic regression odds ratio 1.1, 95% confidence interval of 0.6-2.0). The abolition of premature uterine contractions during intravenous magnesium sulphate therapy does not correlate with serum magnesium levels.

Premalignant lesions of the uterine cervix in a large cohort of Israeli Jewish women.

Israeli Jewish women are at low risk for cancer of the uterine cervix. In view of absent screening programs in Israel, there are only scarce data available with regard to results of PAP smears. The aim of this study was to assess the incidence of premalignant cervical lesions in the largest sample of PAP smears reported so far from Israel. We retrospectively analyzed the results of 297,849 PAP smears, which had been examined in a single laboratory, during 9 years (1991-1999). The incidence of low- and high-grade squamous intraepithelial was 0.69% and 0.29%, respectively. Our data indicate similar incidence rates for premalignant lesions in Jewish Israeli women as observed in Western countries, but no increase during the study period. In spite of relatively high incidence rates for premalignant lesions of the uterine cervix, the incidence rate for invasive cervical cancer remains conspicuously low. For unknown reason the conversion rate from premalignant cervical lesions to invasive cancer is lower in Israeli Jewish women than in European and North American women. We discuss possible reasons for this phenomenon and suggest that at this time mass screening for cervical cancer in Israel may probably not be justified.

Reproductive performance following midtrimester termination of pregnancy.

The aim of the study was to determine the impact of midtrimester abortion with extra-amniotic PGE(2) on future fertility and reproduction. Two hundred and fifteen women were enrolled. The mean induction-to-abortion interval was 21.3 h. The complication rate was 11.7%. Twenty women (9.3%) were lost to follow-up, 82 patients (38.1%) used contraception. Spontaneous pregnancy occurred in 110 out of 113 women who desired fertility (97%). Three patients were defined as infertile but conceived following treatment. The average time between the abortion and the next conception was 15.9 months (range 1-77 months). Seventy patients (63.7%) delivered at term. Premature delivery occurred in 18 patients (16.4%). Eighteen women aborted spontaneously in the first and 3 in the second trimester. One extrauterine pregnancy occurred. Second-trimester abortion with extra-amniotic PGE(2) is a safe procedure with a low rate of complication. Apparently it does not affect future fertility, but may be associated with an increased rate of premature deliveries in future gestations.

Extra-amniotic prostaglandin E2 for midtrimester termination of pregnancy in live fetuses vs. fetal demise.

This study compared the course of midtrimester termination of pregnancies with fetal demise and those with a viable fetuses by extra-amniotic prostaglandin (PG) E(2). A total of 275 women who underwent second trimester abortion with extra-amniotic PGE2(2) were divided into two groups: 95 patients (35%) with fetal demise and 180 women (65%) with a live fetuses. Extra-amniotic PGE2(2) was administered in doses of 200 micro g every 2 h up to 20 doses. Bumm curettage was performed in the majority of the patients. We compared the duration and complication rate between the groups. The median induction to abortion interval was significantly shorter in the fetal demise group (13 vs. 21 h) than in the live fetus group. Mean gestational ages and complication rates were similar. Midtrimester termination of pregnancy with extra-amniotic PGE2(2) is a safe method with a low complication rate. In cases of pregnancy with fetal demise extra-amniotic PGE2(2) is associated with a significantly shorter induction to abortion interval than with a live fetus.

[The management of HIV patients during surgery and in the delivery ward: anesthetic considerations].

To date a total of more than 50 million individuals worldwide have been infected with HIV and more than 20 million have died from the disease. Two thirds of the known carriers of HIV 36 million worldwide, live in Africa. In Israel, as of December 31, 2000, there are a total of 2,843 reported carriers and 165 persons alive with AIDS. On the basis of future projections of increasing incidence of HIV/AIDS in obstetric patients undergoing anesthesia and surgery, obstetricians and anesthesiologists should be aware of the disease and its impact on anesthetic techniques and possible interactions between anesthetic drugs and HIV therapeutic agents. Surgical staff members should be knowledgeable and updated concerning safety precautions during surgical and anesthetic procedures.

Laparoscopic surgery for extrauterine pregnancy in hemodynamically unstable patients.

STUDY OBJECTIVE: To assess the feasibility and safety of laparoscopic surgery in treatment of ectopic pregnancy in hemodynamically unstable women. DESIGN: Three-year observational study (Canadian Task Force classification II-2). SETTING: Tertiary university hospital. PATIENTS: One hundred one women with ectopic pregnancy who underwent laparoscopic surgery, 18 with substantial intraabdominal bleeding and with clinical signs and symptoms of hemodynamic instability. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Compared with stable patients, hemodynamically unstable women had significantly more free blood in the abdomen (1244 +/- 590 vs 173 +/- 301 ml, p <0.0001), had significantly lower hemoglobin levels (7.8 +/- 1.4 vs 11.9 +/-1.4 g%, p <0.0001), and required significantly more frequent blood transfusions (83% vs 3.6%, p <0.0001). Similarly, their hemodynamic values such as pulse rate and blood pressures were worse. Among these women, 15 (83%) had a tubal pregnancy, 2 had an interstitial pregnancy, and 1 had a tubal abortion. Those with tubal pregnancy who were hemodynamically unstable underwent salpingectomy. Only one required conversion to laparotomy. No major intraoperative or postoperative complications occurred, and all women made a full and uneventful recovery. CONCLUSION: Improved anesthesia and cardiovascular monitoring, together with advanced laparoscopic surgical skills and experience, justifies operative laparoscopy for surgical treatment of ectopic pregnancy even in women with hemodynamic instability.

Methotrexate versus hyperosomolar glucose in the treatment of extrauterine pregnancy.

The aim of this prospective, randomized, double blind study was to compare the efficacy of methotrexate and hyperosmolar glucose injected directly into the extra-uterine gestational sac under laparoscopic vision. The study included twenty women with ectopic pregnancy. Inclusion criteria were intact tubal pregnancy, not exceeding 4 cm in diameter, rising or plateauing betahCG levels, and no evidence of intra-abdominal bleeding. The patients were treated by laparoscopically guided injection of 3 mL fluid into the area containing the tubal pregnancy. The fluid contained either 25 mg methotrexate (n=9) or 50% glucose (n=9). Daily decrease in betahCG levels was faster in patients treated by methotrexate (median 8.7%) than in those treated by hyperosmolar glucose (median 4.8%), p=0.17. The study was discontinued due to a higher failure rate in the group treated by hyperosmolar glucose. In conclusion, local injection of methotrexate is superior to hyperosmolar glucose. It can be used as an alternative to salpingostomy or salpingotomy whenever laparoscopy is performed for the diagnosis and treatment of extra-uterine pregnancy.