Mechanical ventilation in stroke patients--is it worthwhile?

We assessed the therapeutic efficacy and outcome of mechanical ventilation (MV) in patients with acute respiratory failure (ARF) following ischemic stroke (IS) or intracerebral hemorrhage (ICH), retrospectively graded by patients with IS (n = 881) and ICH (n = 108) admitted to our service during 11 years, according to the severity of their clinical state and to whether we employed MV. Outcome was recorded in terms of survival and duration of MV and compared with patients with neuromuscular (NM) diseases. We found a very high in-hospital mortality in stroke patients who were treated with ventilation (90.5% for IS and 87.5% for ICH) compared with NM patients (29%). We conclude that MV in stroke patients with ARF is not life-saving, and its use should be considered only after considering other potentially important factors.

Correlation between cutaneous reaction in vaccinees immunized against smallpox and antibody titer determined by plaque neutralization test and ELISA.

The correlation between skin reaction, exhibited by vaccinees immunized against smallpox, and antibody titer determined by plaque neutralization and ELISA, was evaluated. Twenty eight out of 35 young adults (vaccinated at infancy and at the age of 8 years), who were injected with vaccinia virus, displayed a major skin reaction a week later. An increase of four-folds and more, in antibody titer against vaccinia virus, is generally considered positive immunization take-up against smallpox. According to this criterion, only 17 of the vaccinees were found positive by plaque neutralization, while 25 by the indirect micro-ELISA. Thus, there were eight vaccinees who were considered immunized by the ELISA, (seven of them also according to the skin reaction), but not by the plaque neutralization test.

Disorders of excessive daytime sleepiness--an update.

Disorders of excessive daytime sleepiness (EDS) constitute a major health hazard, since impaired alertness may lead to accidents and poor quality of life, and some of them are associated with increased cardiovascular morbidity and mortality. Many disorders of EDS are neurological diseases (e.g. narcolepsy and periodic limb movements in sleep, PLMS). The largest group of disorders causing EDS consists of sleep-related disturbances of breathing, where neuroregulatory mechanisms play a major role in pathophysiology. Many patients with neurodegenerative and neuromuscular diseases suffer from sleep disturbances associated with EDS. Therefore, neurologists must be acquainted with the differential diagnosis of EDS and the major categories of sleep disorders causing it. The present update focuses on major sleep disorders causing EDS, and approaches the topic from the neurologist's perspective. Rather than being an extensive review, this update includes recent data on epidemiology, pathophysiology, diagnosis and treatment of obstructive sleep apnea and related conditions (increased upper airway resistance syndrome, central sleep apnea), as well as of narcolepsy and PLMS. Also included are recent data concerning EDS in neurodegenerative (Alzheimer's disease, Parkinson's disease, multiple system atrophy) and neuromuscular disorders.

Estimation of Parkinson's disease survival in Israeli men and women, using health maintenance organization pharmacy data in a unique approach.

The aim of this work was to estimate in an incident cohort of pharmacy-based PD patients the survival of men and women accounting for age at treatment initiation and to compare their gender-specific survival with that of the general Israeli population. A population-based cohort of 4,848 incident pharmacy-based PD cases with definite/probable/possible certainty was previously identified using a drug-tracer approach for 1999-2008. Survival analysis was performed for two time scales: survival after treatment initiation (disease duration), and life-time survival (life expectancy). Kaplan-Meier curves and Cox regressions were used to compare survival across gender. Gender-specific SMRs were calculated from national rates and were compared using Poisson regression. During the follow-up from first purchase of any anti-parkinsonian drug (mean 4.0 ± 2.6 years, range 2 months-10 years), 1,266 (26 %) of the cases died. Younger age at first anti-parkinsonian drug purchase and female gender were associated with increased survival after treatment initiation (HR = 1.089, 95 % CI 1.080-1.098 for 1-year age increase; HR = 0.716, 95 % CI 0.640-0.800, females vs. males). Life-time survival increased with older age at first anti-parkinsonian drug purchase and female gender (HR = 0.759, 95 % CI 0.746-0.771 for 1-year age increase; HR = 0.694, 95 % CI 0.621-0.776, females vs. males). Sensitivity analysis on a sub-cohort of definite cases (n = 2501) yielded similar results. In comparison to the general Israeli population, mortality among pharmacy-based PD patients was significantly increased (SMR(men) = 1.69, 95 % CI 1.57-1.81, SMR(women) = 1.49, 95 % CI 1.37-1.62), differently between genders (p < 0.01). Female gender was associated with longer, perhaps more benign disease course, and longer life expectancy. Earlier age at anti-parkinsonian drug initiation increased disease duration, but was associated with shorter life expectancy.

Periodic febrile confusion as a presentation of complex partial status epilepticus.

A 75-year-old woman was evaluated for recurrent episodes of fever she experienced periodically every 4-5 weeks over the last 12 months, lasting 2-3 days each. The fever was associated with continuous complex partial seizures, paralleled the seizure activity and returned to normal after the seizures had ceased. The ictal EEG recordings showed rhythmic bitemporal 3-4 Hz activity; the interictal recordings showed a spike and wave discharge over the right fronto-temporal region. Carbamazepine effectively controlled both the seizures and the fever; the latter was presumed to be an inherent manifestation of the seizure activity.

Should sleep EEG record always be performed after sleep deprivation?

Sleep deprivation (SD) is a known activator of epileptiform EEG activity in patients with epilepsy. In the workup of these patients, EEG recordings are performed following SD both in the awake state and during sleep. The latter significantly increases the duration and the cost of the examination; the specific yield of sleep tracing in single-session wake-sleep record after SD has not been evaluated in adult patients. Our study tried to answer this question, analyzing consecutive recordings of 76 adult patients who had an epileptiform abnormality in the SD record. Thirty-five of the patients were treated with antiepileptic drugs at the time of the study. After SD of 24-26 h, 1000-1500 mg of chloral hydrate were administered; an 18-channel standard awake EEG was performed, followed by 30 min sleep recording. Epileptiform activity was recorded in the wake part only in 7 (9%, 3 focal, 4 generalized); in 39 (51%) the activity was seen in both awake and sleep parts (21 focal, 5 focal with secondary generalization and 13 generalized); and in 30 (40%) it was found in the sleep part only (23 focal, 1 focal with secondary generalization and 6 generalized). Whenever epileptiform activity was apparent in both parts of the recording, its configuration and localization were identical in the sleep and the wake EEGs. This phenomenon was observed in both treated and untreated patients. In combined wake-sleep recording following SD in adults, sleep tracing may reveal epileptiform activity not demonstrated during the preceding wake EEG. However, if epileptiform activity appears already in the wake recording, subsequent sleep tracing may be redundant.

The persistence of neutralizing antibodies after revaccination against smallpox.

Persistence of neutralizing antibodies after revaccination against smallpox was studied. Single serum samples from 140 revaccinated donors were tested for neutralizing antibodies using the plaque reduction assay. The donors, aged 21-49 years at sampling, had been vaccinated in infancy and revaccinated at 8 and 18 years; they formed seven groups of 20 men each, revaccinated about 3, 5, 10, 15, 20, 25, and 30 years before sampling. The differences in mean titer among groups were insignificant (P greater than .01). The titer significantly decreased during the first 3 years after the revaccination but remained stable for at least 30 years thereafter (geometric mean titer, 10.5; 95% confidence interval, 6.8-16.4). The results suggest that there is probably no need for routine revaccinations beyond the primary and two revaccinations; nevertheless, persons at high risk should be revaccinated regardless of their vaccination status.