Matti Iivanainen

Preceding infection as an important risk factor for ischaemic brain infarction in young and middle aged patients

The role of preceding infection as a risk factor for ischaemic stroke was investigated in a case-control study of 54 consecutive patients under 50 years of age with brain infarction and 54 randomly selected controls from the community matched for sex and age. Information about previous illnesses, smoking, consumption of alcohol, and use of drugs was taken. A blood sample was analysed for standard biochemical variables and serum cholesterol, high density lipoprotein cholesterol, triglyceride, and fasting blood glucose concentrations determined. Titres of antimicrobial antibodies against various bacteria, including Staphylococcus, Streptococcus, Yersinia, and Salmonella and several viruses were determined. Febrile infection was found in patients during the month before the brain infarction significantly more often than in controls one month before their examination (19 patients v three controls; estimated relative risk 9·0 (95% confidence interval 2·2 to 80·0)). The most common preceding febrile infection was respiratory infection (80%). Infections preceding brain infarction were mostly of bacterial origin based on cultural, serological, and clinical data. In conditional logistic regression analysis for matched pairs the effect of preceding febrile infection remained significant (estimated relative risk 14·5 (95% confidence interval 1·9 to 112·3)) when tested with triglyceride concentration, hypertension, smoking, and preceding intoxication with alcohol. Although causality cannot be inferred from these data and plausible underlying mechanisms remain undetermined, preceding febrile infection may play an important part in the development of brain infarction in young and middle aged patients.

Clinical features and viral serologies in children with multiple sclerosis: a multinational observational study

BACKGROUND The full spectrum of clinical manifestations and outcome, and the potential importance of regional or demographic features or viral triggers in paediatric multiple sclerosis (MS), has yet to be fully characterised. Our aim was to determine some of these characteristics in children with MS. METHODS 137 children with MS and 96 control participants matched by age and geographical region were recruited in a multinational study. They underwent structured clinical-demographic interviews, review of academic performance, physical examination, disability assessment (MS patients only), and standardised assays for IgG antibodies directed against Epstein-Barr virus, cytomegalovirus, parvovirus B19, varicella zoster virus, and herpes simplex virus. FINDINGS MS was relapsing-remitting at diagnosis in 136 (99%) children. The first MS attack resembled acute disseminated encephalomyelitis (ADEM) in 22 (16%) of the children, most under 10 years old (mean age 7.4 [SD 4.2] years). Children with ADEM-like presentations were significantly younger than were children with polyfocal (11.2 [4.5] years; p<0.0001) or monofocal (12.0 [3.8] years; p=0.0005) presentations. Permanent physical disability (EDSS>or=4.0) developed within 5 years in 15 (13%) of the 120 children for whom EDSS score was available. 23 (17%) had impaired academic performance, which was associated with increasing disease duration (p=0.02). Over 108 (86%) of the children with MS, irrespective of geographical residence, were seropositive for remote EBV infection, compared with only 61 (64%) of matched controls (p=0.025, adjusted for multiple comparisons). Children with MS did not differ from controls in seroprevalence of the other childhood viruses studied, nor with respect to month of birth, sibling number, sibling rank, or exposure to young siblings. INTERPRETATION Paediatric MS is a relapsing-remitting disease, with presenting features that vary by age at onset. MS in children might be associated with exposure to EBV, suggesting a possible role for EBV in MS pathobiology.

Cancer incidence of persons with Down syndrome in Finland: A population-based study

Individuals with Down syndrome (DS) have a predisposition to leukaemia and testicular cancer, but data on the incidence of cancers are yet sparse. A cohort of 3,581 persons with DS was identified from a National Registry of Finnish persons with intellectual disability collected between 1978 and 1986 and followed‐up for cancer incidence until 2002. Standardised incidence ratios (SIRs) were defined as ratios of observed number of cancer cases to those expected from the national cancer incidence rates, by age and sex. The overall cancer risk was equal to that of the general population, but a significantly high risk of leukaemia (SIR 10.5, CI 95% 6.6–15.8) and testicular cancer (SIR4.8, CI 95% 1.8–10.4) was found.

Seizures Associated with Propofol Anesthesia

Propofol is a new, fast‐acting intravenous (i.v.) anesthetic. Involuntary movements or epileptic sei zures have occurred during or after propofol‐induced an esthesia in ∼50 reported cases; a third of the patients have had epilepsy. We report 5 patients with seizures in association with propofol anesthesia. A female epileptic patient developed severe status epilepticus; the other patients with short‐lasting seizures had no previous epi lepsy. Although propofol has been used in treatment of patients of status epilepticus, the risk of precipitation of epileptic seizures warrants consideration especially when planning anesthesia for epileptic patients.

Adults With ADHD Benefit From Cognitive—Behaviorally Oriented Group Rehabilitation: A Study of 29 Participants

Objective: In clinical practice, a growing need exists for effective nonpharmacological treatments of adult ADHD. The authors present results from a cognitive—behaviorally oriented psychological group rehabilitation for adult ADHD. Method: A total of 29 adults with ADHD participated. Rehabilitation consisted of 10 or 11 weekly sessions. Participants were assessed with self-ratings (checklist for ADHD based on the Diagnostic and Statistical Manual of Mental Disorders , Beck Depression Inventory II, Symptom Check List-90 [SCL-90], Brown ADD Scale for Adults [BADDS]), and the ratings of their significant others (BADDS) 3 months prior to treatment, at the beginning of treatment, and at the end of treatment. Also, the Wender Utah Rating Scale questionnaire was completed prior to rehabilitation. Results: Rehabilitation resulted in reduced self-reported symptoms in 16 ADHD-related items of SCL-90, BADDS total score, and BADDS subdomains of activation and affect. Conclusion: Results suggest that cognitive—behavioral group rehabilitation can be suitable in treating adult ADHD. (J. of Att. Dis. 2008; 12(3) 218-226)

Clinical guidelines for the management of epilepsy in adults with an intellectual disability

Clinical guidelines exist for the treatment of chronic epilepsy and epilepsy in women (2). This publication provides guidance for the clinician investigating and managing epilepsy in adults who have an intellectual disability as defined by an Intelligence Quotient (IQ) of less than 70, onset in the developmental period and difficulties with adaptive functioning.

Consensus guidelines into the management of epilepsy in adults with an intellectual disability

BACKGROUND Epilepsy has a pervasive impact on the lives of people with intellectual disability and their carers. The delivery of high-quality care is impacted on by the complexity and diversity of epilepsy in this population. This article presents the results of a consensus clinical guideline process. RESULTS A Delphi process identified a list of priority areas for the development of evidence-based guidelines. All guidelines were graded and consensus on scoring was achieved across the guideline group. CONCLUSION There is a dearth of high-quality evidence from well-constructed studies on which to base guidance. However, the development of internationally derived consensus guidelines may further support the management of epilepsy in adults with an intellectual disability.

Cognitive changes as early signs of HIV infection

ABSTRACT‐ Neuropsychological examination was performed on 13 patients and 10 matched controls to assess the brain involvement of patients with human immunodeficiency virus (HIV) infection. HIV‐infected patients showed a significant decline in visuomotor, visuoconstructive and practical abilities as well as in motorfree visuospatial performance and repeating a long sentence. These findings could not be explained by the concomitant mental depression of these patients. Neither were they associated with any particular stage of HIV infection. The results suggest that mild cognitive changes may be detected even in the early stages of HIV infection, when examined by appropriate neuropsychological methods.

Causes of Death in Institutionalized Epileptics

Summary: To assess the causes of death in institutionalized epileptics, the patient records, death certificates, and other data from the only hospital for epileptics in Finland (Vaajasalo Hospital) were reexamined. During the years 1900–1976, 179 inpatients in Vaajasalo Hospital died; this was 12.1% of all inpatients. The most common causes of death were as follows: pneumonia in 40 cases, seizures in 34 cases (single seizure in 18 and status epilepticus in 16), drowning in 29 cases, stroke in 10 cases, and heart infarct in 9 cases. Chronic intoxication caused by phenytoin and/or phenobarbital was a common supplementary factor leading to death in patients who died of pneumonia or seizures. Thirteen deaths were recorded as suicides or suspected suicides (11 by drowning and 2 by strangulation). The results reflect the severe epilepsy and the poor conditions of the patients, as well as the poor condition of the local facilities in the past. The information obtained should be useful in the effort to improve medical care for these patients.

Collagen metabolism of the skin in Marfan's syndrome

Abstract 1. The metabolism of collagen in Marfans syndrome was studied by using punch biopsy specimens of skin from patients with Marfans syndrome and from healthy control subjects. In addition, the urinary hydroxyproline excretion of the patients with Marfans syndrome was measured. 2. 1. The skin specimens were subjected to extraction with 0.14 M and 1.0 M sodium chloride successively. In Marfans syndrome, the mean concentration of 0.14 M sodium chloride-soluble collagen was found to be 2–3-fold that of the control subjects. The mean concentration of 1.0 M sodium chloride-soluble collagen was also higher in Marfans syndrome, but the difference from the controls was smaller than in the 0.14 M sodium chloride-soluble collagen fractions. 3. 2. Despite the increased content of neutral salt-soluble collagen, the concentration of insoluble or total collagen was not significantly changed. 4. 3. The incorporation of [ 14 C]proline into [ 14 C]hydroxyproline of dermal collagen in vitro was greatly increased in Marfans syndrome. The increase in the uptake of the isotope was of about the same magnitude in both the soluble and insoluble collagen fractions of the skin. 5. 4. The urinary excretion of hydroxyproline was elevated in 2 of the 5 patients with Marfans syndrome. The results suggest that an increase in the turnover rate of collagen is the principal change in the metabolism of collagen in Marfans syndrome. However, a possible slight change in the rate of conversion of soluble collagen to insoluble, mature collagen fibres cannot be wholly excluded on the basis of the present results.