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To compare octreotide with injection sclerotherapy in the treatment of acute variceal haemorrhage, patients admitted with gastrointestinal bleeding and oesophageal varices confirmed by endoscopy were randomised to receive either emergency sclerotherapy with 3% sodium tetradecyl sulphate or octreotide (50 micrograms intravenous bolus plus 50 micrograms per h intravenous infusion for 48 h). At the end of the study period (48 h), the octreotide group also had sclerotherapy to obliterate the varices. 100 patients were recruited. Demographic features including the aetiology of portal hypertension and the Child-Pugh's grading of the two groups were similar. Bleeding was initially controlled in 90% of patients by emergency sclerotherapy and in 84% by octreotide infusion (95% confidence interval 0-19.5, p = 0.55). There were no significant differences between the two groups in early (within 48 h of randomisation) rebleeding (16% vs 14%), blood transfusion (3 units vs 3.5), hospital stay (5 days vs 6 days), or hospital mortality (27% vs 20%). No notable side-effects were associated with octreotide. We conclude that octreotide infusion and emergency sclerotherapy are equally effective in controlling variceal haemorrhage.

Basilar artery occlusion developed in a 34 year old woman 2 months after adopting unusual neck postures during yoga practice. On angiography, her basilar artery was filled with intraluminal clot while the vertebral arteries were normal. We postulate that a severe reduction in blood flow and possibly an intimal tear triggered thrombosis of the vertebral artery and that the final stroke mechanism was artery-to-artery embolism.

A chronic carrier state of Salmonella spp is present in 0.15% of the population, and is believed to be related to the presence of a diseased gallbladder. We present a patient with common bile duct (CBD) stones, whose bile cultures repeatedly indicated Salmonella typhi, despite an adequate course of antibiotic treatment. The carrier state was abolished after removal of the CBD stones 4 months later. The chronic carrier state may be related to biofilm formation on the surface of the CBD stones. The removal of the biliary stones, which are the most likely reservoir for Salmonella spp, may be a crucial step in eradication of the carrier state.

The biliary excretion of imipenem-cilastatin studied by endoscopic cannulation of the common bile duct in patients with complete obstruction and in a group without obstruction showed that despite a 24-h prophylaxis, the bile obtained from patients with obstruction immediately after cannulation contained neither imipenem nor cilastatin, while there were 2 and 5% of peak concentrations in serum for imipenem and cilastatin, respectively, in the bile from patients without obstruction. Biliary excretion of both compounds increased rapidly after decompression, reaching a maximum of 15% of peak levels in serum within 2 h. Twenty-four hours after drainage, the biliary excretion of the drugs further improved. We conclude that since biliary obstruction impairs excretion of antibiotics, drainage is necessary for the control of sepsis in obstructed cholangitis.

The first known document on epilepsy in China appeared in The Yellow Emperor's Classic of Internal Medicine, Huang Di Nei Ching, written by a group of physicians around 770-221 B.C. The description of epilepsy in this book and in many others later published was confined to generalized convulsive seizures. No documentation of absence or simple partial seizures was provided. The first classification of epilepsy, probably by Cao Yuan Fang in A.D. 610, listed five types of epilepsy: "Yang Dian," "Yin Dian," "Feng (Wind) Dian," "Shih (Wet) Dian," and "Lao (Labor) Dian." Later, other classifications named seizures after the cry of animals whose cry the "epileptic cry" resembled, or after "visceral organs" believed to be responsible for the seizures. The concept of partial versus generalized seizures, however, was not observed in any of these classifications. The treatment of epilepsy, based on principles of "Yin Yang Wu Xing," consisted of herbs, acupuncture, and massage.

The awareness, understanding, and attitudes toward epilepsy in 1,278 men and women were surveyed in Henan, China in 1988. Results showed that 93% had read or heard about epilepsy; 77% knew someone who had epilepsy; 72% had seen someone who was having a seizure; 57% would object to having their children associate with persons with epilepsy in school or at play; 87% would object to having their children marry a person with epilepsy; 53% believed that epileptic persons should not be employed in jobs as other persons are; 16% believed that epilepsy was a form of insanity; 40% did not know the cause of epilepsy; 10% did not know what an epileptic attack was like; and 17% did not know what to recommend if their friends or relatives had epilepsy. The relationship between the responses and the respondents' age, sex, marital status, number of offspring, level of education, occupation, and residence was analyzed. Education reduced the respondent's prejudice against play and employment, but did not change their objection to marriage and appeared to have reinforced their linking epilepsy with insanity. As compared with the surveys conducted in Western countries, our survey showed that awareness of epilepsy in China was greater, if not the same, but the attitudes toward epilepsy were much more negative.

A 28-year-old woman developed complex partial seizures at the age of 17 years and was treated with phenytoin sodium. Five years later she developed myasthenia gravis, and phenytoin was replaced by valproic acid and phenobarbital. She required plasmapheresis (PP). During one course of PP, total and unbound concentrations of valproic acid and phenobarbital were measured in serum sampled before, during, and after PP and in plasma removed by PP. It was determined that the magnitude of loss of valproic acid or phenobarbital by PP was small, and the changes of unbound/total ratio did not reach clinical importance.

A young woman presented with a 4-month history of retinal and vertebrobasilar ischemia. Angiography demonstrated narrowing of major branches of the aortic arch. Intractable, severe retroorbital pain of the right eye developed after a middle cerebral artery stroke. During 4 weeks of aggressive immunosuppressive therapy including IV high dose bolus corticosteroids and pulse cyclophosphamide, her neurologic deficit improved transiently, but her retroorbital pain persisted. She died of staphylococcal sepsis and pneumonia. An autopsy demonstrated thrombotic or fibrous occlusion, with minimal inflammation, of extracranial arteries.

Focal neurologic deficits, particularly hemiplegia, are occasionally observed in the pediatric migrainous population during the headache attack and are often mistaken for other neurologic or neurosurgical conditions. Clues to the correct diagnosis, illustrated by three patients in this report are: (1) rapid spontaneous recovery from the acute neurologic deficit, (2) striking electroencephalographic abnormalities, frequently consisting of focal slow waves during the acute stage, with rapid resolution, (3) significant past history of recurrent episodes, and (4) positive family history of migraine. Review of previously reported cases indicates that cerebral arteriography in the acute stage should be avoided if the clinical syndrome is typical. Preliminary results of prophylactic treatment with propranolol are encouraging; smaller dosage than those previously recommended sometimes can be effective.

In a case of repeated syncope of abrupt onset and questionable origin, we utilized the continuous ambulatory cassette recorder to document simultaneous electroencephalography/electrocardiography (EEG/ECG) changes. Recording during a spontaneous episode established the cardiogenic origin. Problems in differential diagnosis of syncope and seizure are discussed. With this new instrument, if the initial event in ECG abnormality (as in the present case), further cardiologic study is indicated. If epileptiform EEG activity is primary, neurologic investigation is the direction to pursue; if there is nonepileptiform EEG slowing without ECG abnormality, diagnosis of syncope of noncardiac origin (e.g., hypotension, hypoglycemia) should be considered.

The EEG in the acute stage of herpes simplex encephalitis (HSE) can show a variety of abnormalities, including uni- or bilateral periodic sharp waves or attenuation of amplitude, focal or generalized slow waves or epileptiform discharges, or electrical seizures. No specific EEG patterns are pathognomonic for HSE, but a focal or lateralized EEG abnormality in the presence of encephalitis is highly suspicious of HSE. In the acute stage, EEG appears to be more sensitive than computerized tomography or radioisotope brain scanning. The EEG findings tend to differ in the course of illness, and the periodic discharges occur only during the acute stage. The EEG findings in either the acute stage or long-term follow-up do not predict the chance of survival or severity of disability, and EEG changes appear to lag behind the clinical changes. EEG results can become normal in both adults and neonates when the acute stage is over.

Sudden permanent blindness of cerebral origin, in addition to severe abdominal pain, hypertension, convulsions, and peripheral neuropathy developed in a 21-year-old woman, a victim of acute intermittent porphyria. Findings of the pathological examination of the brain showed extensive infarction in both occipital lobes. The pathological changes were consistent with anoxia. We discuss and review the literature of the possibility of "vasospasm" of both posterior cerebral arteries. Follow-up studies with serial EEG showed either focal epileptogenic activity or diffuse slow waves. The most consistent epileptic discharges were found in the occipital regions. The favorable response to the treatment of seizures with carbamazepine in this patient might encourage further clinical trials.

In a double-blind study of 34 randomly assigned depressed inpatients, antidepressant-induced electroencephalogram (EEG) abnormalities were compared in amitriptyline-treated versus bupropion-treated patients. Drug-free baseline EEGs plus one or more repeat EEGs under pharmacokinetic steady state conditions were obtained. Of the 34 patients, eight developed EEG abnormalities. Seven were on amitriptyline and one was on bupropion (chi 2 = 13.77, df = 3, p less than 0.01). All but one of the amitriptyline-treated patients with EEG abnormalities had plasma concentrations above its therapeutic range (150 to 250 ng/ml), whereas all with normal EEGs were within or below this range.

A patient with an unusual "compulsion" to induce syncope over a period of years by bilateral compression of the carotid arteries subsequently had recurrent seizures. The EEG showed patterns typical of cerebral ischemia during the syncope and epileptogenic foci in both temporal lobes after sleep deprivation. It is difficult to distinguish between seizure and syncope associated with involuntary movements when making a differential diagnosis. We hypothesize that the frequent self-induced ischemic insult to the brain caused a cicatrix to develop, which in turn caused the frequent seizure disorder; and that because this ischemia functioned as a stimulus to the reward site in the limbic system, the patient repeatedly induced it.

Thirty eight patients with a history of diet-induced migraine were studied with recording of clinical responses, electroencephalography in resting state, in response to photic stimulation, and to hyperventilation and visual evoked potentials. Tests were carried out on an initial baseline day and on a second day, after challenge with chocolate, red wine, cheese, and fasting. Lateralized headache occurred in sixteen subjects (42%), four with scintillating scotomata. Electroencephalograms were abnormal on Day 1 and/or Day 2 in twelve subjects (32%), most abnormalities being non-specific slow waves. In three cases there were paroxysmal features. Electroencephalographic response to hyperventilation was calibrated and was found to be exaggerated in eight subjects (21%) on either Day 1 or Day 2; such response was not related to the occurrence of a headache. Photic simulation showed high frequency driving response (so called "H" response) in all 16 individuals who developed headache but in only 14 out of 22 (64%) who did not (p less than 0.01). Pattern reversal visual evoked responses were normal and failed to show any difference in latency or amplitude between headache responders and non-responders.

Herpes simplex encephalitis (HSE) is the most common form of sporadic encephalitis in man and usually results in death or permanent neurologic deficit. Neonatal HSE does not show the characteristic anatomic localization in the temporal lobe observed in adults and in older children which suggests that the disease process is different in this age group. The abnormalities observed with radionuclide brain imaging and computed tomography (CT) are more diffuse and bilateral. The clinical outcome of the disease is highly dependent on early institution of therapy. Therefore, early diagnosis is critical. Knowledge of neonatal HSE imaging patterns may alert the clinician to the proper diagnosis.

Syncope with and without convulsion was studied in unselected blood donors in a community blood center. Convulsive syncope occurred in 0.03% of all blood donors and was more commonly observed when nursing personnel were alerted to its possible occurrence. It was more common in men. Although tonic extensor spasm was the most common convwithout convulsion was studied in unselected blood donors in a community blood center. Convulsive syncope occurred in 0.03% of all blood donors and was more commonly observed when nursing personnel were alerted to its possible occurrence. It was more common in men. Although tonic extensor spasm was the most common convwithout convulsion was studied in unselected blood donors in a community blood center. Convulsive syncope occurred in 0.03% of all blood donors and was more commonly observed when nursing personnel were alerted to its possible occurrence. It was more common in men. Although tonic extensor spasm was the most common convulsive movement, other complex convulsive phenomena occurred, some simulating epileptic seizure. No statistical difference in changes of pulse or blood pressure was found between subjects with convulsive versus nonconvulsive syncope. Similarly, no difference was found between subjects with tonic spasm and those with other convulsive phenomena, nor between those with "early" and those with "delayed" reactions. Marked individual variation may exist in the susceptibility of the central nervous system to ischemia. Some individuals appear to be predisposed to development of seizures in situations of global cerebral ischemia such as occur in hypotension and bradycardia.