Status epilepticus. Clinical features,pathophysiology, and treatment.

During the past two decades, substantial progress has been made in the understanding of the clinical features, classification, pathophysiology, central nervous system consequences, and treatment of status epilepticus. The most commonly used drug regimens have advantages and disadvantages, and, in this review, I recommend a protocol for the treatment of status epilepticus. An important concept in the approach to patients in generalized tonic-clonic status epilepticus is that treatment should be administered within a predetermined time frame. Clinical and experimental research indicates that continuous seizure activity for longer than 60 to 90 minutes may result in irreversible brain damage. As our understanding of the basic mechanisms of neuronal function and seizure generation advances, it is expected that more specific and novel approaches to the treatment of status epilepticus will emerge.     

Cigarette smoking,nicotine dependence,and treatment.

Since the 1988 Surgeon General''s report on nicotine addiction, more attention is being given to nicotine dependence as a substantial contributing factor in cigarette smokers'' inability to quit. Many new medications are being investigated for treating nicotine withdrawal and for assisting in long-term smoking abstinence. Medications alone probably will not be helpful; they should be used as adjuncts in comprehensive smoking abstinence programs that address not only the physical dependence on nicotine but also the psychological dependence on cigarette smoking.     

The treatment of perinatal addiction. Identification,intervention, and advocacy.

Women of reproductive age who use and abuse psychoactive drugs and alcohol present a special challenge to primary care physicians. There are compelling medical reasons for identifying and intervening with pregnant women who are addicted or have alcoholism. The teratogenicity of all drugs of abuse and alcohol, the risk of infection with the acquired immunodeficiency syndrome (AIDS), and the potential for full recovery of a pregnant woman from addiction are some of the reasons that identification and intervention in the problem are indicated. Whether encountered in the clinic setting or in private practice, chemically dependent pregnant or postpartum women are usually responsive to appropriate physician interventions that include a detailed and caring confrontation- and advocacy-oriented support. Complex legal and ethical issues surround perinatal addiction including the role of toxicologic screening, reports to child welfare services, issues in noncompliance, and interdisciplinary case management.     

Plasmodium falciparum hyperparasitaemia in children. Risk factors, treatment outcomes, and gametocytaemia following treatment

The risk factors associated with hyperparasitemia at presentation and after treatment with different antimalarial drug regimens were evaluated in 1,048 children enrolled prospectively in seven antimalarial drug trials between July 1996 and September 2003 in a hyperendemic area of southwestern Nigeria. The outcomes of treatment of hyperparasitaemia, and gametocyte carriage following treatment were also evaluated. The children were assigned to one of seven treatment groups: chloroquine (CQ) only; pyrimethamine-sulfadoxine (PS) only; amodiaquine (AQ) only; CQ plus chlorpheniramine (CQCP); PS combined with CQ or AQ (COM); PS combined with probenecid (PPS); and halofantrine (HF). Hyperparasitaemia was found in 100 (9.5%) of the 1,048 children at enrolment (day 0). Following oral therapy, 1.2% of all patients (i.e. 13 patients) became hyperparasitaemic, which developed in all patients by day 1 of follow-up. In a multiple regression model, age < or = 5 years, and a core temperature (oral or rectal) > or = 39.5 degrees C were found to be independent risk factors for hyperparasitaemia at enrolment. Following therapy, the cure rate on day 14 was significantly lower in those treated with CQ compared to other treatment groups. Severe resistance (RIII) response to treatment occurred significantly more frequently in those with hyperparasitaemia at enrolment than in those without, and was seen in five and one child with hyperparasitaemia who were treated with CQ and CQCP, respectively. Gametocyte carriage was insignificantly lower at enrolment and at all times following treatment in children with hyperparasitaemia than in age- and gender-matched children without hyperparasitaemia who received the same treatment. The results are discussed in the light of management of uncomplicated hyperparasitaemia in children in endemic settings.     

Survival with bladder cancer,evaluation of delay in treatment,type of surgeon,and modality of treatment.

OBJECTIVE--To determine whether length of delay before treatment; specialty and grade of the surgeon; and use made of surgery, radiotherapy, and chemotherapy influenced the survival of patients with cancer of the bladder, after adjusting for case severity. DESIGN--Retrospective cohort study. SETTING--South East and South West Thames health regions. PATIENTS--609 men aged under 75 resident in the South Thames regions who had been registered as new cases of bladder cancer in 1982, 35 of whom were excluded, leaving 574 eligible patients. Analysis was based on 75% retrieval rate for case notes. MAIN OUTCOME MEASURES--Duration of survival from date of diagnosis of the bladder tumour. RESULTS--10 prognostic variables were used to adjust for case severity. The median delay from referral to first treatment was 48 (interquartile range 27-84) days. Treatment after a short delay was associated with shorter survival because of the early treatment of more severe cases. Consultants treated 68% of patients, trainee surgeons treated less severe cases. Initial treatment was by a urologist in 67% of cases, but the specialty of the surgeon was not associated with prognosis. The associations of radiotherapy, cystectomy, and systemic chemotherapy with survival were interpreted in terms of selection bias as well as therapeutic effect. CONCLUSION--Case severity was the most important influence on survival and influenced length of delay before treatment, grade and specialty of the surgeon, and main treatment allocation. After adjusting for case severity variations in these processes of care were not strongly associated with variations in survival.     

Population study of causes,treatment, and outcome of infertility.

Specialist infertility practice was studied in a group of 708 couples within a population of residents of a single health district in England. They represented an annual incidence of 1.2 couples for every 1000 of the population. At least one in six couples needed specialist help at some time in their lives because of an average of infertility of 21/2 years, 71% of whom were trying for their first baby. Those attending gynaecology clinics made up 10% of new and 22% of all attendances. Failure of ovulation (amenorrhoea or oligomenorrhoea) occurred in 21% of cases and was successfully treated (two year conception rates of 96% and 78%). Tubal damage (14%) had a poor outlook (19%) despite surgery. Endometriosis accounted for infertility in 6%, although seldom because of tubal damage, cervical mucus defects or dysfunction in 3%, and coital failure in up to 6%. Sperm defects or dysfunction were the commonest defined cause of infertility (24%) and led to a poor chance of pregnancy (0-27%) without donor insemination. Obstructive azoospermia or primary spermatogenic failure was uncommon (2%) and hormonal causes of male infertility rare. Infertility was unexplained in 28% and the chance of pregnancy (overall 72%) was mainly determined by duration of infertility. In vitro fertilisation could benefit 80% of cases of tubal damage and 25% of unexplained infertility--that is, 18% of all cases, representing up to 216 new cases each year per million of the total population.     

Latent M. tuberculosis infection--pathogenesis, diagnosis, treatment and prevention strategies

One third of the earths population is infected with Mycobacterium tuberculosis (Mtb), but only 5-10% of the infected individuals develop active tuberculosis (TB) over their lifetime. The remaining 90-95% stay healthy and are called latently infected individuals. They are the biggest reservoir of the tubercle bacilli and identifying the cases of latent TB is a part of the global plan of TB control. From the clinical point of view detection of latent TB infections (LTBI) in individuals with the highest active TB risk including cases of HIV infection, autoimmune inflammatory diseases or cancer, is a priority. This review summarizes the recent findings in the pathogenesis of latent TB, its diagnosis, treatment and prevention.