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INTRODUCTION: Video EEG monitoring (VEM) is an important tool for characterizing clinical events suspected as seizures. It is also used for pre-surgical workups in patients with drug-resistant epilepsy (DRE). In-hospital VEM high cost, long admission waiting periods and some other inconveniences led to an interest in home VEM (HVEM). However, because antiseizure medications cannot be reduced at home, HVEM may require longer monitoring. While the economic aspect is one of the main motivations for HVEM, the cost of HVEM lasting several weeks has not been assessed. METHODS: We modeled the cost of HVEM for 8 weeks and compared it to the cost of 1-week in-hospital VEM. Additionally, we modeled the per-patient cost for a combination of HVEM and in-hospital VEM, considering that if in a proportion of patients HVEM fails to achieve its goal, they should undergo in-hospital VEM with drug reduction. RESULTS: The average cost of HVEM up to 4-6 weeks of monitoring was lower than that for the 1-week in-hospital VEM. Combining the 3-week HVEM with 1-week in-hospital VEM (if needed) reduced the per-patient cost by 6.6-28.6% as compared to the situation when all the patients with DRE were referred to the in-hospital VEM. CONCLUSIONS: A prolonged intermittent HVEM can be cost-effective, especially if the minimal seizure frequency is about one seizure per week. The study findings support directing efforts into clinical trials and technology development.
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Ambulatory "at home" video-EEG monitoring (HVEM) may offer a more cost-effective and accessible option as compared to traditional inpatient admissions to epilepsy monitoring units. However, home monitoring may not allow for safe tapering of anti-seizure medications (ASM). As a result, longer periods of monitoring may be necessary to capture a sufficient number of the patients' stereotypic seizures. We aimed to quantitatively estimate the necessary length of HVEM corresponding to various diagnostic scenarios in clinical practice. Using available seizure frequency statistics, we estimated the HVEM duration required to capture one, three, or five seizures on different days, by simulating 100,000 annual time-courses of seizure occurrence in adults and children with more than one and <30 seizures per month (89% of adults and 85% of children). We found that the durations of HVEM needed to record 1, 3, or 5 seizures in 80% of children were 2, 5, and 8 weeks (median 2, 12, and 21 days), respectively, and significantly longer in adults -2, 6, and 10 weeks (median 3, 14, and 26 days; p < 10-10 for all comparisons). Thus, longer HVEM than currently used is needed for expanding its clinical value from diagnosis of nonepileptic or very frequent epileptic events to a presurgical tool for patients with drug-resistant epilepsy. Technical developments and further studies are warranted.
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Exposure to agricultural insecticides, together with yet incompletely understood predisposing genotype/phenotype elements, notably increase the risk of Parkinson's disease. Here, we report findings attributing the increased risk in an insecticide-exposed rural area in Israel to interacting debilitating polymorphisms in the ACHE/PON1 locus and corresponding expression variations. Polymorphisms that debilitate PON1 activity and cause impaired AChE overproduction under anticholinesterase exposure were strongly overrepresented in patients from agriculturally exposed areas, indicating that they confer risk of Parkinson's disease. Supporting this notion, serum AChE and PON1 activities were both selectively and significantly lower in patients than in healthy individuals and in carriers of the risky polymorphisms as compared with other Parkinsonian patients. Our findings suggest that inherited interactive weakness of AChE and PON1 expression increases the insecticide-induced occurrence of Parkinson's disease.
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Acetilcolinesterase/genética , Arildialquilfosfatase/genética , Predisposição Genética para Doença , Inseticidas/efeitos adversos , Doença de Parkinson Secundária/induzido quimicamente , Polimorfismo Genético , Acetilcolinesterase/sangue , Adulto , Idoso , Arildialquilfosfatase/sangue , Inibidores da Colinesterase/efeitos adversos , Expressão Gênica , Variação Genética , Genótipo , Humanos , Israel , Desequilíbrio de Ligação , Pessoa de Meia-Idade , Doença de Parkinson Secundária/genética , Intoxicação , População RuralRESUMO
BACKGROUND: Anogenital pruritus is defined as an itch localized to the anus, perianal, and genital skin. Anogenital pruritus is usually a symptom of an underlying disorder of the skin or mucosa or a consequence of anorectal pathology. When no demonstrable cause is found, anogenital pruritus is often described as "idiopathic". OBJECTIVE: To investigate the role of lumbosacral radiculopathy in the pathogenesis of anogenital pruritus. METHODS: Included in the study were consecutive patients with anogenital pruritus. Radiographs and nerved conduction studies were performed in all patients. Needle electromyography studies and computerized tomography were performed when necessary. Nerve conduction studies included measurement of distal sensory and motor latency, conduction velocity, and F-responses of the peroneal and tibial nerves. Patients with confirmed radiculopathy were treated with paravertebral injection of a mixture of triamcinolne acetonide and lidocaine. Response to the injections was assessed using visual analogue scales by the patients. Mean scores before and after treatment were compared using paired t tests. RESULTS: Included in the study were 20 patients with anogenital pruritus. There were 18 men (90%) and 2 (10%) women. The mean age was 52.7 years (standard deviation [SD] 11.7 years). In 16 patients (80%), radiographs demonstrated degenerative changes of the lower spine. In 16 patients (80%) the presence of lumbosacral radiculopathy was confirmed by nerve conduction studies. Fifteen patients (75%) were treated with paravertebral injections, with significant decrease in mean pruritus score as assessed by the patients (6.3 [+/-2.8]; 4.5 [+/-2.7], before and after treatment, respectively, P = .033). CONCLUSION: "Idiopathic" anogenital pruritus may be attributable to lumbosacral radiculopathy. Paravertebral blockade may be used for alleviation of symptoms in patients with anogenital pruritus.
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Prurido/etiologia , Radiculopatia/diagnóstico , Canal Anal , Feminino , Genitália , Humanos , Região Lombossacral , Masculino , Pessoa de Meia-Idade , Nervo Fibular , Radiculopatia/complicações , Escroto , Nervo TibialRESUMO
PURPOSE: To describe a case of quadriceps tendon rupture in a patient with postanoxic choreoathetotic movements. CASE REPORT: A 20-year-old man was admitted to a rehabilitation hospital after anoxic brain injury. As a result of the injury, he developed continuous flowing choreoathetotic movements. He contracted fever and swollen and painful right knee, and only when periarticular edema decreased did a suprapatellar gap appear and quadriceps tendon rupture was diagnosed. CONCLUSIONS: Considering the possibility of tendon rupture when evaluating a patient with non-volitional movements and 'arthritic' presentation in a rehabilitation setting, may prevent delay of quadriceps surgical repair.
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Atetose/complicações , Coreia/complicações , Traumatismos dos Tendões/etiologia , Adulto , Artrite/diagnóstico , Diagnóstico Diferencial , Erros de Diagnóstico , Humanos , Masculino , Ruptura Espontânea , Traumatismos dos Tendões/diagnósticoRESUMO
STUDY OBJECTIVES: To evaluate the effect of body position on REM-related obstructive sleep apnea (OSA) patients. DESIGN: Retrospective analysis. PATIENTS: 100 consecutive adult OSA patients (apnea-hypopnea index [AHI] > or = 5) who had > or = 10 min of REM sleep in both supine and lateral postures. REM-related OSA was defined by previously used criteria (REM AHI/Non-REM (NREM) AHI > or = 2) and was compared with data from Not-REM-related OSA (REM AHI/NREM AHI < 2). MEASUREMENTS AND RESULTS: Most (93%) of the REM-related OSA patients (n = 45) had a mild-moderate syndrome, compared to 50.9% in the Not-REM-related OSA patients (n = 55). REM-related OSA patients had a lower apnea index (AL), AHI, supine and lateral AHI, and NREM AHI, but similar REM AHI compared to the Not-REM-related OSA group. For the entire group, the following sequence was observed: AHI REM supine > AHI NREM supine > AHI REM lateral > AHI NREM lateral. Also, for the REM-related and Not-REM-related OSA patients, the interaction between supine posture and REM sleep led to the highest AHI. However, the average length of apnea and hypopneas during REM sleep was similar in the supine and lateral postures. CONCLUSIONS: During REM sleep, the supine position is associated with increased frequency but not increased duration of apneas and hypopneas. These body position effects prevail over the differences between REM-related and Not-REM-related OSA patients.
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Polissonografia , Postura , Apneia Obstrutiva do Sono/diagnóstico , Fases do Sono , Sono REM , Decúbito Dorsal , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Apneia Obstrutiva do Sono/etiologiaRESUMO
OBJECTIVES: Neuropsychiatric symptoms related to aciclovir or valaciclovir treatment have been a problem since aciclovir was introduced in the early 1980s. We have previously found that subjects with aciclovir-related neuropsychiatric symptoms have increased serum concentrations of aciclovir's main metabolite, 9-carboxymethoxymethylguanine (CMMG). The aim of this study was to investigate whether CMMG was present in the CSF of aciclovir- or valaciclovir-treated subjects with or without neuropsychiatric side effects that appeared during therapy. METHODS: We investigated retrospectively CSF collected from 21 aciclovir- or valaciclovir-treated subjects. Of these, 9 were subjects with neuropsychiatric signs and symptoms and 12 were asymptomatic subjects, including 10 subjects from a valaciclovir multiple sclerosis trial and 2 subjects with recurrent herpes encephalitis. RESULTS: CMMG could only be detected in the CSF of subjects with neuropsychiatric symptoms and signs (median CMMG concentration 1.0 micromol/L, range 0.6-7.0). The concentration of CMMG was below the limit of quantification (<0.5 micromol/L) in asymptomatic subjects (P < 0.001). All patients with neuropsychiatric signs and symptoms, except one, had acute renal function impairment or chronic renal failure. CONCLUSIONS: These results are consistent with the hypothesis that CMMG is involved in the development of neuropsychiatric side effects in aciclovir- or valaciclovir-treated patients. Measurement of CMMG in CSF and/or serum is a promising tool in the diagnostic procedure for aciclovir- or valaciclovir-treated patients with neuropsychiatric symptoms and may help to differentiate between side effects and herpes encephalitis.
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Aciclovir/análogos & derivados , Antivirais/efeitos adversos , Guanina/análogos & derivados , Transtornos Mentais/induzido quimicamente , Síndromes Neurotóxicas/etiologia , Valina/análogos & derivados , Aciclovir/efeitos adversos , Aciclovir/farmacocinética , Aciclovir/uso terapêutico , Antivirais/farmacocinética , Antivirais/uso terapêutico , Guanina/líquido cefalorraquidiano , Humanos , Transtornos Mentais/líquido cefalorraquidiano , Síndromes Neurotóxicas/líquido cefalorraquidiano , Estudos Retrospectivos , Valaciclovir , Valina/efeitos adversos , Valina/farmacocinética , Valina/uso terapêuticoRESUMO
We reviewed the records of all patients with recurrent seizures and severe head injury-induced traumatic intracranial hemorrhage (TIH) between 1989 and 2003 in three Israeli medical centers. We identified 52 cases (44 males, mean age=43+/-19 years, range=8-84; 8 females; mean age=74+/-12 years, range=48-85). Twenty-seven (52%) had additional known risk factors for TIH, e.g., older age, alcohol abuse, and anticoagulant use. All five children and adolescents had mental retardation. Approximately one-half of patients with seizures and TIH have additional risk factors for TIH. Non-mentally retarded children and adolescents with seizures are probably at low risk of developing TIH. Women less than 70 years old with seizures are much less prone to TIH than men. In young "otherwise healthy" patients with epilepsy, suboptimal treatment seems to be an important factor in the occurrence of TIH.
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Acidentes por Quedas , Epilepsia/complicações , Hemorragia Intracraniana Traumática/etiologia , Convulsões/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Intoxicação Alcoólica/complicações , Anticoagulantes/efeitos adversos , Anticonvulsivantes/uso terapêutico , Criança , Epilepsia/tratamento farmacológico , Feminino , Humanos , Deficiência Intelectual/complicações , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de RiscoRESUMO
The cerebellum is known to have inhibitory effects on seizures. Nevertheless, cerebellar dysplastic lesions can be epileptogenic. We report a patient presenting with epilepsia partialis continua (EPC) following a hemorrhagic cerebellar lesion. Possible pathophysiological mechanisms are discussed.
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Doenças Cerebelares/complicações , Hemorragia Cerebral/complicações , Epilepsia Parcial Contínua/etiologia , Doenças Cerebelares/patologia , Eletroencefalografia/métodos , Eletromiografia/métodos , Feminino , Seguimentos , Gliose/etiologia , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodosRESUMO
Involvement of cranial nerves was rarely reported in various rickettsioses. We present here for the first time a case of peripheral facial paralysis associated with Rickettsia typhi infection.