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The syndrome of involuntary craniofacial lingual movements in the setting of acute intensive care-acquired quadriplegia (critical illness neuromyopathy) following sepsis-associated encephalopathy has not been previously described. We suggest a localization and treatment for this disabling condition.Three patients (2 female) from our center were quadriplegic from critical illness neuromyopathy when they developed involuntary craniofacial lingual movements following sepsis-associated encephalopathy.Extensive investigations failed to identify an etiology for the abnormal movements. Movements were of large amplitude, of moderate speed, and semi-rhythmic in the jaw, tongue, and palate, persistent and extremely bothersome to all patients. Injection with Botulinum toxin type A was very beneficial.Involuntary craniofacial lingual movements in the setting of flaccid quadriplegia following sepsis-associated encephalopathy are consistent with focal craniofacial brainstem myoclonus and constitutes a new syndrome. Botulinum toxin type A treatment maybe helpful in treatment.

Hyperacute hepatic failure (HHF) has a high mortality rate that is most commonly due to severe cerebral edema. However, brain swelling and marked clinical and EEG suppression are potentially reversible, even though the same findings are associated with a very poor neurological outcome in anoxic-ischemic encephalopathy. We present three cases that illustrate neurological recovery despite severe brain swelling and loss of EEG activity. All patients recovered conscious awareness, including one who transiently lost cranial nerve reflexes. Despite deep coma, markedly suppressed EEG and brain edema, aggressive control of ICP may lead to good recovery in acute hepatic failure.

The authors report a case of a 71-year-old man who developed myoclonic status epilepticus and coma after daily ingestion of colloidal silver for 4 months resulting in high levels of silver in plasma, erythrocytes, and CSF. Despite plasmapheresis, he remained in a persistent vegetative state until his death 5.5 months later. Silver products can cause irreversible neurologic toxicity associated with poor outcome.

Encephalopathy and polyneuropathy occur in 70% of septic patients. The encephalopathy is diffuse, appears early, is often severe, but reverses quickly with successful treatment of the sepsis. The electroencephalogram is a sensitive indicator of the incidence and severity of the encephalopathy, but computed tomograms of the brain and cerebrospinal fluid findings are unremarkable. Critical-illness polyneuropathy develops later and in association with multiple-organ failure. Recovery is more gradual. Difficulty in weaning from the ventilator is an important early manifestation. Electromyography should be routinely performed to establish the diagnosis. The polyneuropathy is a primary axonal degeneration, predominantly of distal motor fibers. A persistent deficit may eventuate in severe cases. Whether muscle is affected as consistently as brain and peripheral nerve, and by the same process, has not been determined. Medications used in critical care units, notably sedatives and neuromuscular blocking agents, often confuse the clinical picture. The neurological pathophysiology is unknown but current evidence suggests that nervous system dysfunction arises through the same mechanisms as for systemic organs in the septic syndrome.

Forty-three patients who had sepsis and multiple organ failure (critical illness) were studied prospectively to determine the incidence and severity of peripheral nerve function and to correlate such function with a number of variables. Electrophysiologic studies indicated a primary axonal degeneration of motor and sensory fibers in 30 (70 percent). Fifteen (30 percent) had the clinical signs of difficulty in weaning from assisted ventilation, weakness of limb muscles, and reduced or absent deep tendon reflexes. Full recovery from the polyneuropathy occurred among the 23 (53 percent) who survived, except three who had a very severe polyneuropathy. A peripheral nerve function index, computed from electrophysiologic measurements, showed statistically significant (p less than 0.01) negative correlations with the time in the critical care unit, and the serum glucose value; the serum albumin level showed a positive correlation. Multiple regression analyses indicated all three factors accounted for 47 percent (r2 = 0.4678) of all potential variables. In a separate analysis, the nerve function index correlated with the amplitude of the diaphragm compound muscle action potential (p less than 0.01). The results were consistent with the polyneuropathy being due to the same mechanisms that are currently postulated to cause dysfunction in this syndrome of other organ systems (including the neuromuscular respiratory system).

Objective: To systematically review outcomes in comatose survivors after cardiac arrest and cardiopulmonary resuscitation (CPR). Methods: The authors analyzed studies (1966 to 2006) that explored predictors of death or unconsciousness after 1 month or unconsciousness or severe disability after 6 months. Results: The authors identified four class I studies, three class II studies, and five class III studies on clinical findings and circumstances. The indicators of poor outcome after CPR are absent pupillary light response or corneal reflexes, and extensor or no motor response to pain after 3 days of observation (level A), and myoclonus status epilepticus (level B). Prognosis cannot be based on circumstances of CPR (level B) or elevated body temperature (level C). The authors identified one class I, one class II, and nine class III studies on electrophysiology. Bilateral absent cortical responses on somatosensory evoked potential studies recorded 3 days after CPR predicted poor outcome (level B). Burst suppression or generalized epileptiform discharges on EEG predicted poor outcomes but with insufficient prognostic accuracy (level C). The authors identified one class I, 11 class III, and three class IV studies on biochemical markers. Serum neuron-specific enolase higher than 33 μg/L predicted poor outcome (level B). Ten class IV studies on brain monitoring and neuroimaging did not provide data to support or refute usefulness in prognostication (level U). Conclusion: Pupillary light response, corneal reflexes, motor responses to pain, myoclonus status epilepticus, serum neuron-specific enolase, and somatosensory evoked potential studies can reliably assist in accurately predicting poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest.

About 40% of patients with cardiac arrest can be resuscitated with restoration of spontaneous circulation and respiration. The overall 1 year survival rate of initially unconscious survivors resuscitated from cardiac arrest has been variably quoted to be between 10 and 25% [1, 2]. Anoxic-ischemic encephalopathy is the principal cause of mortality in at least 30–40% of those who die; only 3–10% return to their previous lifestyle, including employment [3]. Under 1% survive in a persistent vegetative state (PVS) [4]. Since primary cardiac arrest is so common, the problems of assessment and management of anoxic-ischemic encephalopathy are of great importance to the intensivist and emergency physician.

Septic encephalopathy resembles many metabolic encephalopathies and is largely reversible, although some survivors of severe septic illness may have residual cognitive problems. These deficits may relate to microscopic abnormalities in the brain that we have found at autopsy. Biochemical abnormalities are directly related to the severity of the encephalopathy. It is unlikely that organ failure accounts for the early encephalopathy, but multi-organ failure probably contributes to brain dysfunction in advanced sepsis.

Of 49 patients with nonconvulsive seizures studied with continuous EEG monitoring, the overall mortality was 33% (16/49).Of the 23 patients with nonconvulsive status epilepticus (NCSE), 13 died (mortality 57%). Individual variables significantly associated with mortality were age, presence of NCSE, seizure duration, hospital and NICU length of stay, and delay to diagnosis and etiology (acute illness versus remote symptomatic). With multivariate logistic regression, only seizure duration (p = 0.0057, OR = 1.131/hour) and delay to diagnosis (p = 0.0351, OR = 1.039/hour) were associated with increased mortality. Acute symptomatic cases could not be adequately classified as either absence, simple, or complex partial status epilepticus when the impairment of consciousness arose from the initial illness. Current classifications of status epilepticus are inadequate for such cases.NEUROLOGY 1996;47: 83-89

Ipsilateral third nerve palsy with early pupillary enlargement is an important sign of transtentorial herniation from a supratentorial mass lesion. A case of frontal, intraparenchymal haemorrhage is reported in which the first ocular manifestation of transtentorial herniation was enlargement of the contralateral pupil. The ipsilateral pupil dilated only after complete oculomotor palsy of the contralateral eye. After partial frontal lobectomy and removal of blood clot, the ipsilateral third nerve recovered before the contralateral third nerve. Clinical findings localised the contralateral third nerve lesion to an extra-axial site. The possible mechanisms of contralateral third nerve compression are discussed. This seems to be the first example of pupillary enlargement as a false localising sign from a contralateral, supratentorial, intraparenchymal mass lesion.

We report 11 adults who exhibited myoclonic status epilepticus (MSE) after cardiac arrest. Based on pathologic, electroencephalographic, and clinical evidence, we conclude that our patients died from the initial anoxic-ischemic insult rather than as a result of MSE. We suggest that the seizures in these nonsurvivors were self-limited events arising from lethal damage to neurons. Thus, in patients with bilaterally synchronous facial myoclonus, bilateral loss of pupillary or oculovestibular reflexes, and suppression and burst-suppression on EEG, it is not warranted to use anesthetic barbiturates to treat MSE.

The Edinburgh Breast Screening Clinic in its first year completed the initial screening examination of 3005 invited women, who were apparently in good health, aged between 40 and 60 years; 141 were referred for a surgical opinion; 70 women ultimately underwent biopsy and 9 proved to have carcinoma. The indications for biopsy are described together with methods of management of the various lesions.

Myo-inositol was given orally to nine multiple sclerosis patients and nine healthy control subjects. Pattern reversal evoked potential testing was used to assess its effect. The principal positive wave increased in amplitude, duration and area in a dose-dependent manner in the multiple sclerosis group compared with controls. Cerebrospinal fluid concentrations of myo-inositol in multiple sclerosis and controls were similar. The significance of these observations is discussed in relation to recent discoveries in inositol phospholipid function.

The principal ultrasonic signs of death of the fetus in the first 12 weeks of pregnancy are reviewed and illustrated. Several new signs, one probably due to CO2 in the conceptus, are recorded. The use of two-dimensional B scanning and multiplanar stereoscopic sonar is made.

The effects of inbreeding of the sow and plane of nutrition after mating on litter size at 28 days were investigated.Outbred Large White sows were mated at first heat after weaning to inbred boars, and inbred sows to outbred boars, so that both groups of sows carried the same type of embryo. The sows were then placed at random on either high or low planes of nutrition until slaughter 28 days later, when their corpora lutea and number of embryos were counted.Litter size was significantly higher in outbred than in inbred sows by 2·52 ± 0·93 pigs. This resulted from 2·89 ± 0·94 more ova shed and 0·37 ± 0·93 more embryos dying. The general conclusion is that inbreeding of the sow reduces early litter size mainly by depressing ovulation rate.The different planes of nutrition produced negligible differences in within-litter mortality and, therefore, on litter size, but resulted in a marked difference in conception rate. All animals on the high plane were pregnant, whereas on the low plane 25% were empty, this difference being highly significant.Age of the sow, but not her weight, was found to be significantly correlated with number of corpora lutea (r = 0·39). The latter had a correlation with litter size of 0·55 and with mortality of 0·45. The correlation between litter size and mortality was −0·50.Parity increased and inbreeding reduced the length of the uterus which was not, however, significantly correlated with litter size.

With the increasing use of mammography in the diagnosis and follow-up of breast cancer, the question of radiation hazard has become of considerable interest (Ostrum, Becker and Isard, 1973; Samuel, 1973). There can be no doubt that ionizing radiation, given in sufficient quantity, is carcinogenic. There is evidence in a number of clinical reports (MacKenzie, 1965; Myrden and Hiltz, 1969; Mettler, 1969; Mole, 1973; Wanebo et al., 1968) as well as additional evidence from experimental work (Shellabargar et al., 1957). Whether one or two sets of mammograms are sufficient to induce malignant change in a breast is more doubtful. However, in problem cases of breast disease, and in screening procedure for breast cancer where yearly mammograms are the custom, irradiation of the breast can mount up rapidly, and apparently dangerous levels of radiation can be reached. Such levels can be greatly reduced if the rads per exposure are kept low (Young, 1974). There has been speculation on the probable increased incidenc...

In the fall of 1913 the department for the first time published a complete handbook for the bureau of medical inspection, and in that connection made quite extensive changes in the methods hitherto employed in connection with quarantine. Owing to unavoidable delays in connection with the budget, etc., the changes were not put fully into effect until March 15, 1914. Our experience with classified quarantine from March 15 to November 1 has been quite instructive. As a preliminary explanation let me give a summary of the methods of quarantine now enforced by the department. The result sought is to avoid the imposition of all restraint upon the family of the patient when consistent with effective isolation of the patient and "carriers," the object being, in brief, to quarantine the public out and to quarantine the patient in. To this end the following rules will be enforced: A.—Isolation with Trained Attendant

We report two cases of serious intracerebral haemorrhage occurring in young women following their first use of oral medications containing catecholaminergic agents (phenylpropanolamine in combination with ephedrine or pseudoephedrine). Both women were previously well, and there was no evidence for systemic vasculitis, coagulopathy, aneurysm or arteriovenous malformation. Angiography in both cases, performed approximately forty hours following drug ingestion, revealed the beading pattern typical of that seen in previously reported cases of presumed amphetamine-induced "vasculitis." We believe that this arteriographic abnormality is non-specific and should not be construed as necessarily indicative of arteritis.

A comparison of clinical, EEG, and pathologic features was carried out on all cases of autopsy-proven Creutzfeldt-Jakob disease (CJD) studied over the last 10 years. Periodic sharp wave complexes (PSWCs) were present in three but absent in seven patients. Myoclonus was documented in two of the three with and in only one of the seven without PSWCs. The three with PSWCs had severe neocortical and at least mild thalamic involvement; those without PSWCs had more variable disease topography. The diagnosis of CJD should not be rejected if PSWCs are absent.

The figures presented herewith will, I think, be a surprise to many people, even to some of the medical officers of the Public Health and Marine-Hospital Service who have been active in bringing about the result which the figures indicate. A few words of explanation are necessary before the figures themselves are presented. In 1893 Passed Assistant Surgeon J. O. Cobb of the service contributed to the annual report of Surgeon-General Wyman a strong plea for the establishment of special hospitals for the care of tuberculous seamen. The following year Passed Assistant Surgeon Bratton submitted, a very strong plea for the same action. Surgeon-General Wyman took up the plan at once and quickly secured the use of the abandoned military reservation at Fort Stanton, New Mexico. The original plan of Dr. Cobb was to have two sanatoriums, one on the Atlantic, in North Carolina