Psychogenic seizures. A study of 42 attacks in six patients, with intensive monitoring.

Intractable complex partial seizures and seizures of unknown type were studied in 78 patients, six of whom were found to have psychogenic seizures. Evaluation by intensive monitoring included simultaneous six-hour telemetered EEG and videotape recordings and daily determination of plasma antiepileptic drug levels. Diagnosis was determined by assessment of four major criteria: deviation of seizures from characteristics of known seizure types, absence of epileptiform activity in the ictal EEG, absence of slowing in the postictal EEG, and relation of seizure frequency to decreasing plasma concentrations of antiepileptic drugs. No single criterion is sufficient for an unequivocal diagnosis of psychogenic seizures.

Epilepsy in prison: elevated prevalence and no relationship to violence.

The epidemiologic, clinical, and social characteristics of epilepsy were investigated in men entering the Illinois prison system and compared with a matched control group of prisoners without epilepsy. The prevalence of epilepsy was 2.4%, four times higher than the prevalence among men aged 20 to 39 in Rochester, MN. Head trauma was the probable cause of epilepsy among 45% of the prisoners with epilepsy, a much higher percentage than that reported in studies of other populations. In comparison with an age- and race-matched group of prisoners without epilepsy, the epilepsy group was not convicted of more serious or more violent crimes.

Disposition of mephenytoin and its metabolite, nirvanol, in epileptic patients.

We investigated the conversion of mephenytoin to nirvanol in five patients with uncontrolled complex partial seizures. After a 50-mg single oral dose, mean peak mephenytoin level was 0.48 microgram/ml and nirvanol 0.37 microgram/ml. After 400 mg, peak mephenytoin level was 3.9 micrograms/ml and nirvanol 2.5 micrograms/ml. On 400 mg daily, mephenytoin reached a mean steady-state level of 1.5 micrograms/ml. Nirvanol mean steady-state level was 18 micrograms/ml. Mean plasma half-life was 17 hours for mephenytoin and 114 hours for nirvanol. Two patients had reduced seizures during mephenytoin therapy and one a transient increase during drug withdrawal. No toxicity was seen, but mephenytoin was not more effective than phenytoin.

Sequelae associated with head injuries in patients who were not hospitalized: a follow-up survey.

Data about sequelae associated with head injuries in patients presenting at a suburban hospital but not hospitalized were collected from emergency department medical records and two follow-up telephone interviews. During the study period 669 patients with head injuries were discharged from the emergency department. Of these, 288 were asked to participate in the study, 275 (95%) agreed, and 262 (91%) were eventually contacted. Participants and nonparticipants were compared on six variables and differed significantly only on age--younger patients were more likely to be included. Forty-eight hours after trauma, 52% of the respondents suffered headaches, 14% complained of dizziness, and 13% complained of drowsiness. One week after trauma, the complaints were headaches in 27%, dizziness in 11%, and drowsiness in 9%. Twenty-seven per cent had not resumed normal activity at 48 hours after trauma, and 13% had not at 1 week. Sixty-six per cent of the patients followed the patient instructions regarding head injuries.

Urban head injury: a clinical series.

Consecutive head-injured patients admitted to Cook County Hospital in Chicago, Illinois, over a 12-month period were examined upon admission and discharge. Information was collected about the nature of the injury, symptoms, signs, and sequelae for 702 patients. Detailed descriptions of the causes of these injuries, and their correlates, were also obtained.Approximately 80 percent of the patients had localized pain, loss of consciousness and/or posttraumatic amnesia, and associated injuries; 16 percent had a skull fracture, 7.0 percent had an intracranial hematoma, 4.1 percent had early seizures, and 2.4 percent died.Skull x-ray examinations were performed on 93.4 percent of the patients (16.9 percent were positive) and radiographic examination of the cervical spine was performed on 67.2 percent (1.7 percent were positive). Utilization of EEGs, computerized tomography scans, and arteriograms was also assessed.Falls were the leading cause of injury (45.8 percent) for patients under 16 years of age and interpersonal injuries accounted for the majority (55.7 percent) of the injuries to adults. About 15 percent of the adults sustained severe or fatal injuries, compared with only 7 percent of the children.It is concluded that although this set of data suggests new considerations for the prevention of head injuries, the lack of comparative data about the medical correlates of these injuries inhibits similar observations about medical care.

Neurological intensive care in India.

BACKGROUND: Intensive care units need to be optimally utilized especially in developing countries such as India where they are rare and artificial ventilators are available for a limited number of patients. Data concerning the outcome of diverse neurological emergencies are required to enable physicians to make decisions and to advise families of patients on issues such as the institution of artificial ventilation and the use of pressor agents. METHODS: We analysed 271 patients admitted over a 24-month period to our 5-bed neurological intensive care unit, and related the outcome to the occurrence of coma (Group I, n=100), respiratory failure without coma (Group II, n=32) and no respiratory failure or coma (Group III, n=139). Patients with pre-terminal coma alone were included in Group III. RESULTS: Whereas the three groups were similar with regard to age, sex and social class, mortality was entirely different (overall mortality 44%, Group I 86%, Group II 56% , Group III 12%). Only one comatose patient made a good recovery. Among patients requiring ventilatory support, the highest mortality was recorded in comatose patients (62/65; 95%) and the lowest in those with the Guillain-Barré syndrome (6/15; 40%). CONCLUSIONS: We suggest that artificial ventilation be used only in those comatose patients where the underlying cause is potentially reversible such as status epilepticus and that a multicentre study be conducted in the Third World on the prognosis of coma and the use of intensive care units.

An ongoing tragedy: the acquired immune deficiency syndrome (AIDS).

PIP: The AIDS epidemic has, to date, had only a minimal impact in India; however, given the low health status of the population and the lack of adequate health care facilities, the emergence of AIDS on a wider scale would be devastating. India's human immunodeficiency virus (HIV) seropositivity rate now stands at about 2-3/1000 people tested. In what is suspected to be a racially motivated move, the Government of India has embarked on testing all foreign students (most of whom are from Africa) for HIV and is returning all those who test seropositive to their countries of origin. Of concern is the steady increase in HIV infection in professional blood donors (1.5/1000 in late 1988). Mandatory screening of donated blood is prohibitively expensive in India, and none of the 9 companies that manufacture blood products in India test their donors for HIV infection. Another concern is the finding that 1 of every 6 prostitutes in Bombay is infected with HIV. The response of the Indian Government to the AIDS threat has tended to be punitive toward AIDS victims rather than based on a sound preventive strategy. For example, the 1989 AIDS Prevention Bill forces individuals who are infected with HIV to reveal their past sexual partners, empowers authorities to hospitalize AIDS victims and drug addicts, and contains no provisions to protect the human and civil rights of AIDS victims. The mass media have treated AIDS in a sensationalized manner rather than presenting scientific information about the prevention and transmission of the disease. It is essential that the Government of India--and all world governments--realize that punitive measures will do little to reduce the spread of AIDS. Needed, instead, is a global prevention and control effort based on generosity and compassion.^ieng

Complex partial seizures.

Complex partial seizures, the most common of the adult seizure types, originate in the temporal lobe or limbic system. They include spells with emotional content, cognitive defects, hallucinations and automatisms. Video recordings, EEG telemetry and positron emission tomography have provided a better understanding of the electrophysiology of these seizures. Computed tomography reveals lesions in 50 to 70 percent of the patients. Seizures that are intractable to medical therapy can be treated by temporal lobe resection, with benefits in at least 70 percent of patients.

Comparative head trauma experiences in two socioeconomically different Chicago-area communities: a population study.

Although a few epidemiologic studies of head injuries have appeared recently, none have examined the incidence, causes and risk factors for an inner city environment. To overcome this deficiency, the authors visited 35 hospitals and the Office of the Medical Examiner and abstracted data from every chart that described a head injury that had been sustained during a 12-month interval by residents of either of two Chicago-area communities: one located in the inner city, comprised almost entirely of blacks; the other the city of Evanston, a Chicago suburb, about 21% black and 75% white. Denominators came from the 1980 Census. Age-adjusted incidence rates, per 100,000 population, were 403 for the inner city community, 394 for Evanston blacks and 196 for Evanston whites. In each race-community category, males were about 2.5 times more likely than females to sustain a head injury. Mortality rates from head trauma were 32 for the inner city community, 19 for Evanston blacks and 11 for Evanston whites. The leading cause of head trauma and death from head trauma was interpersonal attacks for the inner city residents and vehicle accidents for Evanston residents. Community differences, revealed in this study, and in a comparison of this study with previous reports, are discussed. Finally, methodological differences among these studies are examined in an effort to determine which differences in results reflect actual differences in head trauma experience.

Raeder's syndrome.

Raeder's paratrigeminal syndrome is a disorder manifested by unilateral ptosis, miosis, intact facial sweating, and severe pain in the distribution of the ophthalmic division of the fifth nerve. It is a clinical pattern where, usually, a middle-aged male gets a severe throbbing supraorbital headache accompanied by ptosis and miosis. The headache is intermittently present for several weeks or months. Facial sweating may or may not be affected. This report describes a female with Raeder's syndrome who had unilateral facial anhibrosis.

Active noncompliance as a cause of uncontrolled seizures.

A 26-year-old woman with intractable seizures and fluctuating plasma phenytoin concentrations is described. Noncompliance with prescribed drug regimens was suspected. Phenytoin was first given as a capsule and then as an elixir. Ingestion of the capsule was monitored, and active non-compliance was proved and admitted by the patient. The causes of inadequate plasma phenytoin concentrations are few and can be determined either by specific laboratory methods or by changing the form of the drug.

Seizures and civilian head injuries.

Although several studies have reported on the risk of "early seizures" (seizures occurring within 7 days following a head injury), the reported proportions of patients experiencing these seizures vary from 1.4 to 15%. This wide divergence may be due to problems with methodology such as case selection and definitions of head injury and early seizures. In a series of 702 patients admitted with a head injury to Cook County Hospital (CCH), Chicago, Illinois, 29 (4.1%) had early seizures. This proportion is twice as high as one previously reported in a comparable series. This may reflect an actual difference between the two series or a case selection bias serving to elevate the proportion of patients with early seizures at CCH.

Seizures in relation to head injury.

Seizures have a two-fold relationship with head injury: they can cause a head injury, or they can be the result of a head injury. We compare these two groups in terms of cause, severity, likelihood of sequelae, outcome, radiological investigation, and surgical intervention. Of 702 patients admitted with a head injury to Cook County Hospital (CCH), 25 patients (3.6%) had seizures causing a head injury (Group 1). Another 29 patients (4.1%) experienced a head injury which caused a seizure (Group 2). The remaining 648 patients (Group 3) had no seizure involvement in relation to their injury. Group 1 and Group 3 were similar in terms of severity and sequelae. Group 2, in which a statistically significant increase in both was noted, was dramatically different. It thus appears that seizures indicate increased severity and sequelae in a head injury only when they result from that injury, and not when they cause it. The emergency physician must thus be prepared to distinguish these two situations, for patients in Group 2 have an increased need for neuroradiologic procedures and neurosurgical intervention.