Unusual case of bilateral hand weakness.

A 35-year-old man presented with myalgia and bilateral hand weakness, 3 days after the onset of lethargy, fevers and rigours. The hand weakness caused functional impairment including difficulty pressing keys on his mobile phone. On examination, there was mild bilateral hand weakness with normal reflexes. His serum creatine kinase was mildly raised at 503 U/L (24-195), viral PCR throat swab was negative and electromyogram showed subtle myopathic changes in the distal forearm muscles. Nerve conduction studies found no evidence of neuropathy. Forced vital capacity was reduced on admission (1.5 L) but improved within 24 hours (2.3 L). We gave supportive intravenous fluids and his weakness improved within 48 hours. He was discharged and reported that the weakness had fully resolved within weeks. The diagnosis was viral myositis. Distal forearm myositis rarely follows H1N1 influenza in adults but is an important differential for postinfective neurological symptoms.

Signatures of isomerization in photodissociation of trans- crotonaldehyde probed by multiphoton ionization mass spectrometry.

We report the observation of new isomerization effects in the UV-photodissociation of trans-crotonaldehyde upon multiphoton excitation by the third harmonic (355 nm) pulses of a Nd:YAG laser. A time-of-flight mass spectrometric analysis reveals formation of acetaldehyde, acetyl, and methoxy radical cations as signatures of isomerization processes. A small segment of the multiphoton ionization spectrum of jet-cooled crotonaldehyde is recorded by tuning the laser frequency around 355 nm. An oxetene type transient intermediate in the ground state has been considered for acetaldehyde formation following a photochemical model suggested earlier (Reguero ; et al. J. Am. Chem. Soc. 1994, 116, 2101-2114) for such compounds. Likewise, for methoxy radical formation, a trans-cis isomerization about the C═C double bond has been considered in a triplet surface. Electron ionization mass spectra of the compound are also recorded by varying the electron kinetic energy in the range 11-70 eV. Ionic fragments in the mass spectra of the two ionization processes are dramatically different. Our suggested mechanisms for isomerization and fragmentation channels are substantiated by density functional theory calculations. Combined experimental and calculated data lead us conclude that isomerization occurs in neutral potential energy surfaces prior to dissociation and photoionization.

Carcinoid syndrome from small bowel endocrine carcinoma in the absence of hepatic metastasis.

An 80-year-old male patient presented with abdominal pain, paroxysmal diaphoresis, diarrhoea and vomiting. CT scan revealed a small bowel endocrine carcinoma (or 'carcinoid' tumour), but the absence of hepatic disease. The lesion was excised 'en-bloc'. Intra-operatively, there was wide fluctuation in blood pressure associated with tumour manipulation, with hyper- and hypotension. Carcinoid syndrome usually occurs from gastrointestinal tumours when hepatic metastases occur, causing flushing, diarrhoea, bronchoconstriction and murmurs from cardiac valvular lesions. This patient did not have radiological evidence of hepatic metastasis, but the syndrome could still occur with midgut tumours via local invasion of the retroperitoneal circulation, or by action of substances other than serotonin that do not undergo hepatic metabolism.

Is there a role for pre-operative thrombocytosis in the management of colorectal cancer?

BACKGROUND: High circulating platelet counts have been associated with poor prognosis in a variety of solid tumours such as breast, renal and lung cancer. We investigated the significance of a high pre-operative platelet count on overall survival in patients with stages I-IV colorectal cancer. PATIENTS AND METHODS: 630 Consecutive patients who colorectal cancer resection between 2004 and 2007 with a full blood count taken 14 days prior to the surgery were assessed. Male:female 7:5, median (range) age 73 (40-99 years). Thrombocytosis was defined as platelet count of ≥450 × 10(9)/L. The relationship between platelet count, pathological features and overall survival was assessed. RESULTS: : Mantel-Cox regression showed that platelet count does not predict survival on multivariate analysis (p = 0.067). Thrombocytosis was present in 51/627 (8.1%) of cases. There was no statistically significant difference in mean survival (p = 0.067) observed in patients with platelet count <450 × 10(9)/L (n = 576; 95%CI: 1550.5-1405.4 SE 37.0) versus ≥450 × 10(9)/L (n = 51, CI: 1261.6-955.0, SE 78.2). There was also no correlation between Dukes stage and thrombocytosis. CONCLUSION(S): In our study, pre-operative thrombocytosis is not a prognostic indicator of survival in colorectal cancer patients regardless of pathological stage.

Post-hypoxic myoclonic status: the prognosis is not always hopeless.

A 67-year-old woman abruptly developed acute pulmonary oedema, severe bradycardia and then cardiac arrest while in hospital 6 days after an elective hernia repair. She was resuscitated, intubated and transferred to the intensive care unit. Within 24 hours, she began to display repetitive, generalised myoclonic jerks that failed to respond to therapy with conventional anticonvulsants; an electroencephalogram confirmed myoclonic status. After administration of levetiracetam was begun on Day 3, myoclonic jerks reduced, and there was gradual clinical improvement. By Day 6 after the arrest, the patient was alert and oriented (Glasgow Coma Score, 15/15). Although she died on Day 11 after massive haemoptysis and cardiac arrest, this patient demonstrates the possibility of reasonable neurological recovery despite early onset of myoclonic status.

The importance of acuity, stereopsis, and contrast sensitivity for health-related quality of life in elderly women with cataracts.

PURPOSE: To investigate the relative contribution of visual and other factors to quality of life among elderly women with bilateral cataract. METHODS: Data were analyzed from a trial of first-eye cataract surgery. Visual parameters, general health, and social variables, and disease-specific (VF-14 Index of Visual Function), generic (Euroqol: EQ-5D, London Handicap Scale, Barthel), and intermediate (anxiety, depression, and activity) outcomes were measured at baseline and 6 months later, when approximately half the group had had surgery. RESULTS: Three hundred six participants provided data at baseline, and 289 at 6 months. At baseline, acuity, stereopsis, and contrast sensitivity were all associated with quality of life. Acuity and stereopsis were most strongly and consistently associated. Change in VF-14 was associated with changes in stereopsis and contrast sensitivity, while change in handicap was associated with change in stereopsis. CONCLUSIONS: Acuity, stereopsis, and contrast sensitivity each contributed to quality of life, across a range of measures, in elderly women with cataract. Acuity was marginally the most consistently and generally the most strongly associated, but in some analyses stereopsis was more important. Change in quality of life was associated with change in stereopsis and contrast sensitivity.