Neurovascular Complications of Iatrogenic Fusarium solani Meningitis.

A multinational outbreak of nosocomial fusarium meningitis occurred among immunocompetent patients who had undergone surgery with epidural anesthesia in Mexico. The pathogen involved had a high predilection for the brain stem and vertebrobasilar arterial system and was associated with high mortality from vessel injury. Effective treatment options remain limited; in vitro susceptibility testing of the organism suggested that it is resistant to all currently approved antifungal medications in the United States. To highlight the severe complications associated with fusarium infection acquired in this manner, we report data, clinical courses, and outcomes from 13 patients in the outbreak who presented with symptoms after a median delay of 39 days.

[Hodgkin's lymphoma in otorhinolaryngology]. / Enfermedad de Hodgkin en otorrinolaringología.

OBJECTIVES: To evaluate the implication of Hodgkin's lymphoma (HL) in Otorhinolaryngology. PATIENTS AND METHODS: A longitudinal retrospective study on patients with HL diagnosed, treated and followed-up in our Centre from 1996 to 2010. RESULTS: From 413 individuals having lymphoma, 120 were labelled as HL (29%). Patients were males in 76% and greater incidence was observed in ages between 15 and 30 years old, as well as between 45 and 60. Samples for biopsy from adenopathies were obtained in 84 cases (61 from the neck), and in 15 its origin was extranodal. The most usual finding at physical exploration was the presence of cervical (86%) and axillary nodes (68%), followed by B symptoms (37%). Waldeyer's ring was affected in 4%. The most frequent histopathological variety was classic HL with nodular sclerosis (50%) and mixed cellularity (28%). Patients were usually diagnosed at stages I (28%) and II (47%). Recurrence of disease in the neck after conventional oncologic therapies was detected in 17 patients, in 7 of which the pathologic study had varied. Mortality was 8%. The main unfavourable prognostic factors for neoplasm recurrence were lymphocyte depletion variety, lymphadenopathy larger than 10 cm and B symptoms. CONCLUSIONS: Clinical HL findings are strongly associated with the head and neck area, making its suspicion obligatory in differential diagnosis on cervical nodes.

The impact of intensive patient education on clinical outcome in a clinic-based migraine population.

OBJECTIVE: To determine whether the addition of patient education to routine medical management improves the clinical status of migraine patients and reduces their utilization of healthcare resources. BACKGROUND: Optimal migraine management typically requires effective patient education. Such education often is difficult to accomplish in the busy clinic setting. METHODS: One hundred consecutive patients with migraine presenting to an university-based headache clinic were randomized to receive or not receive a standardized course of didactic instruction regarding migraine biogenesis and management. The course consisted of 3 classes taught by lay migraineurs who themselves previously had undergone intensive training. All patients were evaluated initially and at 1, 3, and 6 months by a neurologist blinded as to the results of randomization. Clinical variables examined included headache frequency/severity, migraine disability assessment (MIDAS) scores, patient compliance, presence versus absence of analgesic use/overuse, and headache-related unscheduled visits or phone calls. Comparisons were made between baseline findings and findings at the 6-month follow-up visit, with the change in mean MIDAS score serving as the primary outcome variable. RESULTS: At 6 months the group randomized to receive intensive education exhibited a significantly greater reduction in mean MIDAS score than the group randomized to routine medical management only (24 vs. 14 points; P < .05). Those patients also experienced a reduction in mean headache days per month and a greater reduction in functionally incapacitating headache days per month, exhibited less analgesic overuse and need for abortive therapy, were more compliant with prophylactic therapy prescribed, and made fewer headache-related calls to the clinic or unscheduled visits. CONCLUSION: Intensive education of migraine patients by trained lay instructors may convey significant benefit to those patients and reduce their utilization of healthcare resources.

Predictors of a negative response to topiramate therapy in patients with chronic migraine.

OBJECTIVE: To identify variables predictive of a negative response to prophylactic therapy with topiramate in patients with chronic migraine. BACKGROUND: While certain of the newer antiepileptic drugs (AEDs) have emerged as promising or definitely effective therapies for migraine prevention, we continue to lack biologic or clinical variables predictive of treatment response to these or other widely used prophylactic therapies. METHODS: A consecutive series of 170 patients with IHS-defined migraine who were experiencing 15 or more days of headache per month were treated with topiramate according to a uniform dosing protocol. Variables examined for their potential value in predicting treatment response included age, gender, prior experience with prophylactic therapy, prior experience with divalproex sodium specifically, headache frequency and, if present, duration of chronic daily headache (CDH). A positive treatment response was defined as a 50% or greater reduction in headache days during the second treatment month relative to the patient's pretopiramate baseline. Only patients who completed the treatment phase and achieved the 50 mg BID target dose were analyzed (efficacy analysis). Each variable prospectively selected was evaluated in regards to treatment outcome via a paired t-test, and a multiple regression analysis of all variables subsequently was performed. RESULTS: A total of 116 patients completed at least 60 days of treatment and consequently were available for analysis. In the efficacy analysis, 45 (38.8%) of the 116 responded positively to topiramate. Neither age nor gender influenced treatment response. Those patients with CDH of more than 6 months duration, patients who previously had tried and failed more than three prophylactic agents and patients who previously had failed to respond to divalproex sodium were more likely to be nonresponders, but after multiple regression analysis the only statistically significant predictor of a negative treatment response was CDH of more than 6 months duration (P<.001). CONCLUSIONS: Patients with chronic migraine who are treated with topiramate may respond positively at a rate approaching that reported from placebo-controlled trials involving topiramate or other AEDs administered to less severely afflicted migraineurs. Our analysis suggests that patients with chronic migraine least likely to respond to topiramate would be those with extensive and negative previous experience with prophylactic therapy, previous failure to respond to divalproex sodium, CDH, and, most notably, CDH of more than 6 months duration.