Improvement In Mental Status Research Articles

Dichloroacetate treatment for mitochondrial cytopathy: long-term effects in MELAS

The long-term effects of the sodium salt of dichloroacetic acid (DCA) were evaluated in four patients with mitochondrial encephalomyelopathy with lactic acidosis and stroke-like episodes (MELAS) carrying A3243G mutation. Oral administration of DCA in MELAS patients was followed for an average of 5 years 4 months. Serum levels of lactate and pyruvate were maintained at around 10 and 0.6 mg/dl, respectively. Serum levels of DCA were 40–136 μg/ml. Symptoms responding to treatment included persistent headache, abdominal pain, muscle weakness, and stroke-like episodes. In contrast, no improvements in mental status, deafness, short stature, or neuroelectrophysiological findings were observed. Adverse effects included mild liver dysfunction in all patients, hypocalcemia in three and peripheral neuropathy in one. None of these adverse events was severe enough to require discontinuation of treatment. To determine suitable indications for DCA therapy, analysis of many more patients who have undergone DCA administration is required.

Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage

Objective To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock. Design During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review. Setting Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day. Population During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms. Methods As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion. Main outcome measures Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart. Results Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output. Conclusions The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

Effects of benzodiazepines on triphasic waves: implications for nonconvulsive status epilepticus.

Nonconvulsive status epilepticus (NCSE) is often diagnosed based on abolition of rhythmic sharp waves by benzodiazepines. It is possible that sharp waves resulting from metabolic (nonepileptic) encephalopathies may also respond to benzodiazepines and are potentially misdiagnosed as NCSE. The authors hypothesized that triphasic waves (TW) resulting from metabolic encephalopathy are abolished by benzodiazepines. They retrospectively identified patients with TW resulting from metabolic encephalopathy who had EEG recordings before, during, and after benzodiazepine administration. Benzodiazepines were given either because of the possibility of NCSE or for a medically indicated purpose. All patients were diagnosed definitively with a metabolic cause of encephalopathy and not NCSE. Ten patients (mean age, 59 years) met the criteria and were reviewed. TW resolved persistently in four patients and intermittently in six patients. Background activity slowed in five patients and was attenuated in five patients. Unresponsive patients did not arouse and three of five drowsy patients became less responsive. Rhythmic sharp waves resulting from metabolic encephalopathy are abolished by benzodiazepines, similar to NCSE, but without improvement in mental status. This suggests that definitive electrographic diagnosis of primary NCSE should not be based entirely on abolition of sharp waves by benzodiazepines. This also implies that gamma-aminobutyric acid neurotransmission is important in the expression of TW.

The impact of seclusion on the treatment outcomes of psychotic in-patients.

The controversial practice of seclusion for the treatment of the acutely emotionally ill continues despite a lack of proven effectiveness. This retrospective cohort study examined the impact of seclusion alone and in combination with other important patient-centred treatment variables (medications), disease severity variables, psycho-social and demographic variables that best predicted outcome (as defined by length of hospital stay and reduced pathology at discharge) for a group of consecutively admitted psychotic in-patients. Comparisons of baseline and outcome measures for secluded and non-secluded cohorts were made via t-test analysis, and patient-related variables were entered as groups for stepwise regression analysis to determine those factors that could best predict outcome. Data were collected via a comprehensive chart review of 85 patients with psychosis, who were consecutively admitted over an 8-month period to a psychiatric in-patient unit of a general community hospital in southern Ontario, Canada. Bigelow's Psychiatric Symptom Assessment Scale (PSAS) was applied to the chart admission and discharge data to determine both initial pathology scores and pathology change scores. Investigator-developed global rating scales measured the early pharmacological and psycho-social variables of interest. Although seclusion itself did not appear to be associated with any more or less improvement in mental status at discharge, seclusion was associated with a 12-day increase in length of hospital stay, raising additional questions about its therapeutic effectiveness. Early medication response together with seclusion predicted 16% of the total variance of length of hospital stay (P = 0.0011) while baseline pathology, being married and being employed together predicted 66% of reduced pathology at discharge (P = 0. 00001). Secluded subjects experienced an earlier age of illness onset, were employed or full-time students, exhibited poorer attitude towards hospital, were more likely to be substance or drug abusers, received greater doses of chlorpromazine-equivalent medications, and had longer lengths of hospital stay than their non-secluded cohorts. Two predictive regression equations were formulated on the basis of these results. This study has raised several questions for further prospective investigation, has validated previous findings in the literature, and has produced new findings that may be of interest to administrators and clinicians providing quality care to this high-risk population.

Hyperperfusion syndrome after bilateral internal carotid stent-supported percutaneous transluminal angioplasty

Spirit of Recovery D. Monthei Nelson (Milwaukee, Wisconsin) Background: Parish nurses integrate mmd, body and as they work with people in the context of their homes and communities, (neighborhood, friends, family, church, agencies), as well as the hospital, nursing home and rehabilitation settings; and they do this over a prolonged length of time. Understanding the Spirit's role in healing the stroke victim is the focus of this paper. Methods: Work with three individuals, their families, caregivers and faith communities over the past 2 1/2 years, as well as a detailed questionnaire resulted in this anecdotal paper. Pm~r is Good Medicine, Larry Dossey, 1996, and Wellness Practitioner, Carolyn Chambers Clark, 1996, were helpful resources. Results: This paper recognizes the spirit as a make or break element to recovery and long term wellness in the stroke patient. Conclusions: Strength of (faith, hope, attitude, soul, will) holds the key to recovery and continuing wellness of the stroke victim. Health care professionals, families, friends, and faith communities who know this and build support and strengthening of this into their caring will enhance their effectiveness and the wellness of those they love immeasurably. 275 Stroke Outcomes in an African-American Population L. Simon, D. Lockridge (Louisville, Kentucky) Background: We reviewed records of all African-American patients diagnosed with stroke over a one year period. Methods: Admissions (n=100) in 1998 were reviewed to identify a primary care physician, health insurance, prophylactic medication prior to admission, length of stay and discharge disposition. Results: Thirty three patients (33%) had no primary care physician. Of this group, twenty five (76%) had Medicare coverage. Average length of stay was 7.8 days (7.2 days for total stroke population). Average length of stay for patients with no health insurance (n=7) was 9.5 days. Twenty patients (20%) took medication for stroke prevention. Thirty five patients (35%) want to in-patient rehabilitation, twenty eight (28%) to extended care, sixteen (16%) to home, fourteen (14%) to home health, and seven (7%) expired. 40% of the total stroke population was discharged home and 17% discharged to an extended care facility. Conclusions: The impact of stroke on African-Americans is more devastating in terms of impaired functional ability requiring extended periods of rehabilitation. Access to healthcare and identification and modification of stroke dsk factors are key elements in reducing stroke incidence and improving outcomes in this population. Hyperperfusion Syndrome after Bilateral Internal Carotid Stent-supported Percutaneous Transluminal Angioplasty G.S. Silva, E.L.V. Costa (Fortaleza-CE-Brazii), A.M. Forteza (Miami-FL) Background The cerebral hyperperfusion syndrome is a well-described complication following carotid endarterectomy for severe carotid stenosis. It has been rarely described following carotid artery stent-supported percutaneous transluminal angioplasty (PTA). Case Report We report the case of a 73-year-old patient who developed left hemiparesis, hemineglect, confusion and seizures after bilateral PTA for high-grade symptomatic internal carotid stenosis. A brain computed tomographic scan showed edematous sulci over the right cerebral hemisphere raising the differential diagnosis of early ischemia versus cerebral hyperperfusion. The patient responded favorably to therapy with intravenous labetalol with considerable improvement of mental status, regaining normal speech and motor function. Single photon emission computerized tomographie scan 8 days after the procedure showed increased perfusion over the right cerebral hemisphere. Conclusion The cerebral hyperperfusion syndrome has to be considered in the differential diagnosis o f complications related to carotid artery stent-supported percutaneous transluminal angioplasty. Pre-Hospital Provider Stoke Knowledge Base Assessment John Bruns, Jr., MD Denise Nassisi, MD Kevin Baumlin, MD Andy Jagoda, MD Objectives: To assess the stroke knowledge base ofprehospital providers (PHPs); to determine their management and transport practices. Methods: An electronic survey administered to 14 emergency medical technicians (EMTs) and 48 paramedics (EMT-Ps) during a stroke symposium. A computer driven interactive system allowed 100% audience participation to prelecture questions. Results: 31% of EMTs and 18% of EMT-Ps reported they are uncomfortable performing a neurologic exam. 42% of EMTs and 17% of EMT-Ps were unaware of the 3 hour thrombolytic therapeutic window. 65% of PHPs transport stroke patients with lights & sirens or pre-notify the receiving hospital. 45% of PHPs failed to recognize blindness or dizziness as possible stroke symptoms. 43% of paramedics did not know the indications for glucose administration in stroke patients with altered mental status. Given a BP of200/110 in a stroke patient, 33% of EMT-Ps were uncertain of management, and 20% would have given a detrimental therapy. Conclusions: Deficits exist in PHPs performance of a neurologie exam and recognition of stroke. Appropriate transport practices and therapeutic interventions varies among PHPs. Enhanced education for PHPs on stroke recognition and management is needed in this new era of stroke management.

Hypoglycemia in multiple trauma victims

The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.

Reversible dementia in idiopathic normal pressure hydrocephalus: A case report

Objective - To present a woman with idiopathic normal pressure hydrocephalus (NPH) showing marked improvement in mental function after shunt operation. Design - Case report.Setting - Primary health care.Patient - The clinical symptoms of gait disturbance, occasional urine incontinence and severely impaired mental function typical of NPH were all present. Although dementia predominated in the clinical picture, the diagnosis was confirmed by computer tomography (CT) and cerebrospinal fluid infusion test and cisternography.Main outcome measures - A marked improvement of mental functions was observed after shunt operation.Results - Mini Mental State Examination score before shunt operation was 9 compared with 20 one year after operation. Also ventricle size was reduced as evaluated by CT scan.Conclusion - This reported case contrasts previous reports concluding that shunt responsive patients have only slight mental disturbances without significant improvement of mental status after shunt operation.

Survival prolongation in HIV-associated progressive multifocal leukoencephalopathy treated with alpha-Interferon: an observational study

A retrospective chart review was conducted to determine the effect of alpha-Interferon (alpha-IFN) on disease progression, symptom palliation, and survival in HIV-associated Progressive Multifocal Leukoencephalopathy (PML). Subjects were HIV seropositive patients diagnosed with PML at the Johns Hopkins Hospital between 1985 and July of 1986. Diagnostic criteria for PML included both clinical symptomatology and histologic or radiographic confirmation. All patients with concomitant CNS infections were excluded. Patients receiving a minimum treatment of 3 weeks of 3 million units of alpha-IFN daily were compared to untreated historical controls. From 104 PML cases reviewed, 77 met the defined criteria for PML. Twenty-one patients had received open-label alpha-IFN treatment in a non-randomized manner for at least 3 weeks, and 32 met criteria for inclusion in the untreated group as historical controls. Deceased treated patients were comparable to deceased untreated patients with respect to age, gender, race, HIV risk factors, AIDS-defining illnesses, and CD4+ counts. CD4+ counts and use of anti-retroviral medications within 6 months of PML onset were higher among those who were living at the time of the study. Among deceased patients, median survival of treated patients was 127.5 days longer than that of untreated patients (Chi-square=4.21, P=0.04). When living and deceased treated patients were combined, the median survival was 325 days (range 35 - 1634) versus 121 days (range 46 - 176) in untreated patients (Chi-square=13.47, P < 0.001). When survival times in untreated patients were left-censored to account for possible survivorship bias in treated patients, survival in treated patients remained significantly prolonged (325 days versus 175.5 days, Chi-square=4.65, P=0.03). In addition, use of alpha-IFN was associated with a significant delay in the onset of memory loss (Chi-square=8.59, P < 0.01). Seven alpha-IFN treated patients showed sustained remissions of several months to over a year, with documented improvements in mental status, aphasia, dysarthria, dysphagia, paresis, and dyscoordination. Moreover, four IFN-treated patients had evidence of MRI lesion regression, although this was not always correlated with clinical remission. Four of 32 untreated patients also reported transient symptomatic improvements. This open-label study suggests that alpha-IFN may delay progression, palliate symptoms, and significantly prolong survival in HIV-associated PML, and we therefore suggest that a controlled clinical trial is warranted.

Does Midazolam Cause Retrograde Amnesia, and Can Flumazenil Reverse That Amnesia?

Does Midazolam Cause Retrograde Amnesia, and Can Flumazenil Reverse That Amnesia?

Nasal Continuous Positive Airway Pressure in Decompensated Hypercapnic Respiratory Failure as a Complication of Sleep Apnea

Cardiopulmonary failure resulting from progression of obstructive sleep apnea (OSA) is treated with endotracheal intubation and mechanical ventilation. This study was conducted to determine whether the use of nasal continuous positive airway pressure (CPAP) would rapidly reverse changes in mental status and hypercapnic acidosis in such patients with decompensated hypercapnic respiratory failure resulting from OSA. Six morbidly obese patients (mean weight, 159 +/- 19 kg) were treated with nasal CPAP and supplemental oxygen. Within 24 h of this treatment, there was a significant increase in pH, from a baseline mean of 7.23 +/- 0.03 to 7.35 +/- 0.01 (p < 0.01), and the mean PaCO2 fell from 80 +/- 4 mm Hg to 64 +/- 4 mm Hg (p < 0.01). In addition, there was a dramatic improvement in mental status within 24 h of therapy with nasal CPAP. None of the patients required intubation and mechanical ventilation. There were no complications attributable to the CPAP delivered by nasal mask. We conclude that CPAP delivered by nasal mask can be safe and effective in rapidly reversing changes in mental status and hypercapnic acidosis in this group of patients with severe respiratory failure, and nasal CPAP obviates the need for endotracheal intubation and mechanical ventilation.

Narcotic Use in the Hospital: Reasonably Safe?

To determine the causes and frequency of overdoses associated with the administration of opioid analgesics in hospitalized patients. Case series. Two acute care teaching hospitals. Eighty-one hospitalized patients who received naloxone for a clinically suspected narcotic overdose. Three investigators reviewed each patient who received naloxone during a 12-month period. The patients were judged to have a narcotic overdose if caregivers documented an immediate improvement in mental status, respiratory rate, or blood pressure after naloxone administration. The number and causes of narcotic overdoses were determined. The frequency of morphine and meperidine overdoses was calculated. The number of incidents reported using incident or adverse drug reaction reports or the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. In the 22 overdoses that occurred, 14 (64 percent) were caused by medication prescribing, compounding, or administration errors and potentially were preventable. The remaining eight patients experienced an overdose despite receiving appropriate amounts of opioids. The frequency of overdoses was 0.4 and 0.2 percent of total patients receiving morphine or meperidine, respectively, at the two hospitals. Nonreporting of these narcotic overdoses was frequent. In one hospital, 1 incident report and 3 adverse drug reactions were reported for 17 overdoses. At the second hospital, 1 incident report and 1 adverse drug reaction were reported for 6 overdoses. None of the patient charts included an ICD-9-CM code that documented the problem. The causes of overdoses are not limited to prescribing and administration errors. Some patients, despite proper execution of appropriate orders, develop a narcotic overdose. Caregivers must be aware of this problem and monitor patients for a decrease in mental status and respiratory rate. In addition, we conclude that an important number of hospitalized patients develop an overdose even though the frequency is low related to the number of patients receiving narcotics.

Geriatric Evaluation and Management: Current Status and Future Research Directions

In the last decade the concept of geriatric evaluation and management (GEM) has been widely discussed in the literature. Studies of GEM have occurred primarily in three settings: inpatient units, outpatient clinics, and specialized types of home care. We have reviewed the literature, focusing on randomized trials, to determine the strength of the evidence for the efficacy of these interventions. Two single-site randomized controlled trials of inpatient GEM units have been conducted and indicate that such units that provide care to targeted disabled older patients probably have a favorable impact on subsequent physical function, rates of institutionalization, and mortality. Two randomized trials of inpatient GEM consultation teams have been conducted. The trial that did not target high-risk individuals showed no benefit while the trial that did target an at-risk group showed that those receiving the service had improvements in mental status and short-term mortality. The results of randomized trials of outpatient GEM clinics to date have been unimpressive. Two trials of in-home GEM by a trained observer tended to show that the service resulted in a reduction in mortality. To date randomized trials of GEM have been very heterogeneous in terms of the type of assessment and subsequent care, the site in which services are delivered, and the manner in which patients are selected for the studies. This limits the ability to compare and extrapolate across studies. In the future there is a need to better clarify the selection of study participants, the exact structure of the assessment intervention provided, and the elements of successful interventions that may be most critical to insuring a good outcome.

Amantadine and the End-Stage Dementia of Alzheimerʼs Type

Significant improvement of mental status was noted with amantadine therapy in three patients in whom autopsy subsequently showed Alzheimer's disease. Two patients showed a dramatic improvement during the treatment. Their mute, immobile states were reversed and they were able to speak a few coherent words. Their mental status deteriorated when the drug was withdrawn. Transient clinical improvement was noted when amantadine was reinstituted. In all patients EEG showed typical repetitive periodic sharp waves (PSW) similar to those seen in Creutzfeldt-Jacob disease. Alterations of PSW accompanied the initial clinical improvement. We speculate that amantadine acts as a central stimulant by enhancing the release of central endogenous dopamine and possibly other neurotransmitters.

Barbiturate-refractory epilepsy: safe schedule for therapeutic substitution.

Barbiturates are considered first line antiepileptic drugs in third world countries due to traditional and economic reasons. This prospective uncontrolled study of 52 patients aged 15 to 64 years (mean 24) demonstrates that patients who become refractory to barbiturates are mainly those with partial seizures with or without generalization or with a focal EEG abnormality (71%). Seizures tend to become refractory approximately 6 years after barbiturates were started. Progressive barbiturate withdrawal over a period of two to 8 months (mean 5) with institution of treatment with carbamazepine, phenytoin or sodium valproate allowed complete barbiturate withdrawal in 42 of the 52 patients (81%). Furthermore monthly seizure frequency in those in whom barbiturates were withdrawn decreased from 7.1 to 1.7 per patient. An improvement in mental status was observed but not measured. These results show that barbiturates should not be first-choice drugs in patients who have a chronic disease such as epilepsy, and indicate a schedule for barbiturate withdrawal which is safe and independent of hospitalization or monitoring of antiepileptic drug serum concentrations.

Infantile spasms syndrome in monozygotic twins. A 7-year follow-up.

The Infantile Spasms Syndrome is a fairly common form of seizures in infancy. Many papers and several books have been published on this syndrome but several aspects are still obscure. In particular, there is some controversy about anticonvulsant treatments and on the question of improvements in mental status. An unusual case of 2 monozygotic twins with by this syndrome, both with clinical manifestations appearing within a few hours on the same day, at 6 months has been followed up for 7 years, giving us the opportunity to understand some aspects of the clinical course of the disease and long term treatment.

Primary Alveolar Hypoventilation syndrome in a 10-year old girl

A 10-year old girl presented with deep cyanosis, right cardiac failure and generalised seizures. The medical history was unremarkable except for neonatal meconium aspiration and a generalised seizure at the age of 4. After treatment of the acute phase, the diagnosis of primary alveolar hypoventilation was established by the following findings: 1. Persistent hypoxia (SaO2 40-100%) and hypercapnia (pCO2 60 - 100 mm Hg), especially during quiet sleep, with prolonged episodes of apnea; 2. impaired ventilatory CO2-response; 3. normal pulmonary function without airway obstruction; 4. no signs of myopathy with normal EMG and diaphragmatic EMG; 5. improvement of ventilation during infusion of almitrine (a chemoreceptor agonist). There were no abnormalities on 24-hours EEG registration. Additional findings were right ventricular hypertrophy with pulmonary hypertension and mental retardation with cerebral atrophy on CT scan. Both were probably the consequence of prolonged hypoxia. Maintenance therapy included doxapram, almitrine and caffeine together with oxygen during sleep. Because this medication was ineffective in preventing nocturnal apnea, mechanical ventilatory assistence was instituted during sleep by means of an external cuirasse ventilator. At present the patient has been treated for 18 months with caffeine and cuirasse ventilation at night. No complications were seen; the therapy proved effective in preventing nocturnal hypoxia and resulted in a marked improvement in mental status, a normal growth and pubertal development and normalisation of cardiac dimensions.

Valproate Sodium in Refractory Seizures

Sodium valproate (N-dipropylacetic acid) is a newly released anticonvulsant drug with a broad spectrum of activity. Twenty-seven children with uncontrolled seizures, predominantly akinetic and myoclonic, were treated with this drug. Encouraging results were noted in those with head-nodding spells, body drops, and myoclonic jerks ("minor motor" seizures). Side effects included occasional gastrointestinal disturbance. No important hepatotoxic complications were noted. Two persons displayed transient neurologic side effects. Of particular interest was the noticeable improvements in mental status noted in 17 of the 27 patients. Some variations in blood level of other anticonvulsant drugs were noted, emphasizing the importance of monitoring these drugs. Valproate sodium provides important improvement in our ability to manage minor motor seizures.

Normalization of brain serotonin by L-tryptophan in levodopa-treated rats.

To test possible biochemical mechanisms by which L-tryptophan may reverse mental side effects of levodopa therapy in parkinsonism we administered levodopa, 250 mg per kilogram intraperitoneally, alone and with L-tryptophan, 500 mg per kilogram intraperitoneally, to rats pretreated with the peripheral dopa decarboxylase inhibitor, carbidopa (25 mg per kilogram). Rats were decapitated 0.5, 1, and 2 hours following amino acid injection and brain levels of amino acids, amines, and acid metabolites were determined. As expected, levodopa alone reduced tryptophan and serotonin and increased dopa and dopamine at the 1 and 2 hour intervals. Concurrent administration of L-tryptophan did not significantly alter the increased dopa and dopamine but did restore serotonin levels to within normal range at all time points. If similar events occur in parkinsonian patients, normalization of brain serotonin and not competitive reduction of brain dopa and dopamine may be the basis for the improvement in mental status.

Prevention of senile and presenile dementia by bishydroxycoumarin (Dicumarol) therapy.

Abstract: Research data from many sources appear to confirm the theory that circulatory insufficiency of the brain plays a major role in the development of senile and presenile dementia. This insufficiency is probably caused most frequently by sclerotic narrowing of the arteries supplying the brain combined with blood sludging or thrombosis in the arteries, capillaries or veins. Experience gained thus far from therapeutic trials in a small number of patients indicates that progression of the dementia can usually be arrested at once by the use of bishydroxycoumarin (Dicumarol). In some patients there has been worthwhile improvement in mental status. These findings suggest that for many patients, early treatment wih Dicumarol may prevent progressive mental deterioration, and thus put senile dementia in the category of a preventable disease.

Minor Motor Epilepsy

The most serious hazard of minor motor epilepsy is the associated mental and motor retardation, or both, which is found, in some degree, in essentially all patients. The use of corticotropin or steroids has been recommended in recent publications. The present study comprises 14 children with minor motor epilepsy, mental retardation, and hypsarhythmic electroencephalographic abnormalities. Corticotropin was given alone in eight cases; corticotropin was followed by triamcinolone in one; cortisoneacetate was given in two cases; prednisone was given in two cases, and triamcinolone was given alone in one case. In four cases there was improvement with respect to seizures, but in no case was there significant improvement in mental status.