Herpes simplex virus (HSV) encephalitis in a young man: an unusual course.

We present a case of cerebral venous sinus thrombosis (CVST) as a rare complication of herpes simplex virus (HSV) encephalitis. A young man with no pertinent medical history was diagnosed with HSV encephalitis. After initial treatment, he showed improvement in symptomatology until day 6 when he acutely developed new neurological deficits. An urgent MRI brain showed changes in left temporal lobe consistent with HSV encephalitis and lack of flow void in superior sagittal sinus. Subsequent magnetic resonance venography confirmed the diagnosis of superior sagittal sinus thrombosis along with thrombosis of bilateral frontoparietal cortical draining veins. Anticoagulation was immediately initiated and oral anticoagulation was continued for 1 year. He made complete recovery subsequently. Our case serves as a reminder for the treating clinicians to consider CVST in patients with HSV encephalitis who develop an unexpected new neurological deficits during early phase of appropriate treatment.

Prospective single-arm study of intraoperative radiotherapy for locally advanced or recurrent rectal cancer.

INTRODUCTION: This study aims to evaluate the feasibility and outcomes of intraoperative radiotherapy (IORT) using high-dose-rate (HDR) brachytherapy for locally advanced or recurrent rectal cancers. Despite preoperative chemoradiation, patients with locally advanced or recurrent rectal cancers undergoing surgery remain at high risk of local recurrence. Intensification of radiation with IORT may improve local control. METHODS: This is a prospective non-randomised study. Eligible patients were those with T4 rectal cancer or pelvic recurrence, deemed suitable for radical surgery but at high risk of positive resection margins, without evidence of metastasis. Chemoradiation was followed by radical surgery. Ten gray (Gy) was delivered to tumour bed via an IORT applicator at time of surgery. RESULTS: There were 15% primary and 85% recurrent cancers. The 71% received preoperative chemoradiation. R0, R1 and R2 resections were 70%, 22% and 7%, respectively. IORT was successfully delivered in 27 of 30 registered patients (90% (95% confidence interval (CI) = 73-98) ) at a median reported time of 12 weeks (interquartile range (IQR) = 10-16) after chemoradiation. Mean IORT procedure and delivery times were 63 minutes (range 22-105 minutes). Ten patients (37% (95% CI = 19-58) ) experienced grade 3 or 4 toxicities (three wound, four abscesses, three soft tissue, three bowel obstructions, three ureteric obstructions and two sensory neuropathies). Local recurrence-free, failure-free and overall survival rates at 2.5 years were 68% (95% CI = 52-89), 37% (95% CI = 23-61) and 82% (95% CI = 68-98), respectively. CONCLUSION: The addition of IORT to radical surgery for T4 or recurrent rectal cancer is feasible. It can be delivered safely with low morbidity and good tumour outcomes.

Cerebral venous thrombosis secondary to ovarian hyperstimulation syndrome.

We report a case of a woman who underwent in-vitro fertilisation embryo transfer treatment for infertility and developed an acute stroke (left hemiparesis and headache). The stroke was caused by cerebral venous thrombosis due to ovarian hyperstimulation syndrome. We review the current background about this uncommon disorder.

Merkel cell carcinoma: 27-year experience at the Peter MacCallum Cancer Centre.

PURPOSE: To retrospectively evaluate the treatment outcome of patients with Merkel cell carcinoma after local and/or regional treatment. METHODS AND MATERIALS: Patients presenting to our center between January 1980 and July 2006 with Merkel cell carcinoma and without distant metastases were reviewed. The primary endpoint was locoregional control. Secondary endpoints were distant recurrence, survival and treatment toxicity. RESULTS: A total of 176 patients were identified. The median age was 79 years. The median follow-up was 2.2 years for all patients and 3.9 years for those alive at the last follow-up visit. The most common primary site was the head and neck (56%), and 62 patients(35%) had regional disease at presentation. The initial surgery to the primary tumor involved (wide) local excision in 140 patients and biopsy only in 28 patients (8 patients had no identifiable primary tumor); 33 patients underwent nodal surgery. Of the 176 patients, 165 (94%) underwent radiotherapy (RT) and 29 of them also underwent concurrent chemotherapy. The median radiation dose was 50 Gy (range, 18-60). Locoregional recurrence developed in 33 patients(19%), with a median interval to recurrence of 8 months. Distant metastases developed in 43 patients(24%). Age, primary tumor size, and RT (no RT vs. < 45 Gy vs. ≥ 45 Gy) were predictive of locoregional control on univariate analysis. However, only RT remained significant on multivariate analysis. The estimated 5-year actuarial rate for locoregional control, progression-free survival, and overall survival was 76%, 60%, and 45%, respectively. CONCLUSION: The locoregional control rate for Merkel cell carcinoma in our study was comparable to those from other series using combined modality treatment with RT an integral part of treatment.

Prognosticating acute symptomatic seizures using two different seizure outcomes.

PURPOSE: This study examined the profiles and prognosis of first acute symptomatic seizure (ASS). Because seizure recurrences may occur in the setting of a persisting or reemerging acute symptomatic cause or in the setting of an unprovoked seizure, we documented the prognosis of ASS in terms of acute symptomatic seizure (AS) or unprovoked seizure (US) recurrence. METHODS: We conducted a prospective study of patients with suspected seizures between April 2004 and December 2005. Patients were classified according to medical history taking, routine clinical evaluation, and expert adjudication, and they were followed for a minimum of 2 years or until death. The Kaplan-Meier method and univariate/multivariate statistical analysis were used to determine prognosis. RESULTS: One hundred five patients with first-ever ASS were identified. For many, first ASS was associated with status epilepticus (29.5%), multiple-onset (>1 seizure within 24 h on day of presentation) (35.2%), and multiple etiologies (22.9%), with a mortality of 30% at 2 years (Kaplan-Meier method). Using AS as outcome, the risk of recurrence following an ASS was 32% at 2 years [mean time to recurrence 20.5 days with epileptiform electroencephalography (EEG) being an independent predictor; p = 0.005, odds ratio (OR) 16, 95% confidence interval (CI) 4.09-62.7]. Using US as outcome, the risk of recurrence following an ASS was 12% at 2 years. DISCUSSION: Although ASS did not associate with a high rate of US recurrence, we demonstrated that ASS was often followed by another AS. This may have implication for short- to medium-term antiepileptic agent therapy, especially when the acute symptomatic cause takes a long time to treat, is prone to reemergence, or is irreversible.

Effects of valproate or lamotrigine monotherapy on the reproductive endocrine and insulin-related metabolic profile in Chinese adults with epilepsy: a prospective randomized study.

Cross-sectional studies have suggested that valproate treatment may be associated with hyperinsulinemia and hyperandrogenism in women. Few prospective data are available. We evaluated the reproductive endocrine and insulin-related metabolic parameters in men and women with untreated epilepsy randomized to valproate (n=44) or lamotrigine (n=37) monotherapy for 12 months. On treatment, there was no significant difference in fasting serum insulin concentrations between the two groups. In women (n=40), there was no significant difference between the two groups in change from baseline in serum total testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, or follicle-stimulating hormone. In men (n=41), follicle-stimulating hormone concentration significantly decreased in patients taking valproate compared with those on lamotrigine as early as 3 months after treatment. Greater attention should be paid to investigate the potential impact of valproate on reproductive function in men.

An epidemiological study of epilepsy in Hong Kong SAR, China.

BACKGROUND: Several specialist clinic-based epidemiology studies suggested low prevalence in Hong Kong Special Administrative Region (HKSAR) of China. Population-based epidemiological data for epilepsy is not available. We performed the first population-based epidemiological survey of epilepsy in this locality. METHOD: We conducted a territory-wide survey. We randomly selected 9547 households from fixed-line telephone directory. We successfully surveyed 17,783 persons of 5178 households by telephone interview. All positive respondents 685 (3.85%) were invited for clinical validation. 127 subjects were validated by board-certified neurologists. RESULTS: Seizure disorders were confirmed in 28 subjects. The crude prevalence of active epilepsy and seizure disorder were estimated to be 3.94/1000 (95% confidence interval (CI): 2.10-6.74/1000) and 8.49/1000 (95% CI: 5.64-12.27/1000), respectively. CONCLUSIONS: The prevalence of epilepsy in HKSAR is more common than previously thought. The data retrieved is useful for planning and allocation of health resources for patients with seizure disorders.

Refractory epilepsy in a Chinese population.

OBJECTIVES: To investigate the proportion of Chinese patients with intractable seizures and the risk factors leading to refractory epilepsy. METHODS: Consecutive patients over 14 years of age attending a Neurology clinic were evaluated. Patients with epilepsy were classified into two groups according to their seizure control: refractory or seizure-free. Epilepsy was classified as idiopathic as defined by age-related onset and typical electroclinical characteristics, symptomatic if secondary to a structural abnormality and cryptogenic if the cause was unknown. Age, sex, epilepsy syndrome classification, aetiology, presence of mental retardation and the number of drugs used were compared between patients with refractory epilepsy and those in remission. RESULTS: Among 260 adolescent and adult patients with a mean age of 34 years (range 15-79), complete seizure control was achieved in 157 (60%) cases. Multivariate binomial logistic regression analysis showed that patients with mesial temporal sclerosis (OR=7.6, 95% CI 3.53-16.4, p<0.01) and the presence of mental retardation (OR=9.39, 95% CI 3.98-22.12, p<0.01) were more likely to develop pharmacoresistant epilepsy. CONCLUSION: In adults the underlying aetiology is an important factor as to whether patients develop intractable seizures. Poor control was also associated with the presence of mesial temporal sclerosis and mental retardation.

Diagnostic value and safety of long-term video-EEG monitoring.

This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.

Association between ABCB1 C3435T polymorphism and drug-resistant epilepsy in Han Chinese.

There is accumulating evidence to suggest that overexpression of efflux drug transporters at the blood-brain barrier, by reducing antiepileptic drug (AED) accumulation in the seizure foci, contributes to drug resistance in epilepsy. P-glycoprotein, encoded by the ABCB1 gene, is the most studied drug transporter. There are conflicting data as to whether the CC genotype of the ABCB1 3435C>T polymorphism is associated with drug resistance in Caucasian patients with epilepsy. We investigated this association in ethnic Chinese. ABCB1 3435C>T was genotyped in 746 Han Chinese patients with epilepsy and 179 controls. Patients with drug-resistant epilepsy were more likely to have the TT genotype compared with those with drug-responsive epilepsy (16.7% vs 7.4%, odds ratio=2.5, 95% confidence interval=1.4-4.6, P=0.0009). Our results contrast with those of studies of Caucasians, and highlight the complexity of the possible role of this polymorphism in AED response in different ethnic populations.

Update on status epilepticus.

Status epilepticus is a medical emergency and is secondary to a range of insults to the central nervous system. The authors reviewed the current management of this disorder in light of the latest developments from recent trials and guidelines. Important principles in management include early recognition of status epilepticus, identification of the underlying cause and prompt treatment to terminate seizures and reduce complications. The role of electroencephalographic monitoring and different treatment regimens are examined.

Stage I non-small cell lung cancer: results for surgery in a patterns-of-care study in Sydney and for high-dose concurrent end-phase boost accelerated radiotherapy.

PURPOSE: To review results of resection or radical radiotherapy in Sydney to inform patients contemplating treatment options for early-stage non-small cell lung cancer (NSCLC). METHODS AND MATERIALS: Sixty-eight resected pathologic stage I patients were identified from a patterns-of-care (POC) study of all 1993 and 1996 NSCLC patients treated at the South Western Sydney Area Health Service and the Northern Sydney Area Health Service. These were compared with 39 clinical stage I patients treated by modern radiotherapy using an accelerated high-dose technique at St George Hospital (SGH). RESULTS: Resected POC patients achieved a median survival rate of 67 months and a 5-year survival rate of 54% (95% CI, 40-66%). SGH radiotherapy patients achieved a median survival rate of 43 months and a 5-year survival rate of 30% (95% CI, 13-48%). On multivariate analysis, the only significant factor is performance status, which may reflect comorbidity burden. Cancer-specific 5-year survival rates for surgery (59% [44-71%]) and for radiotherapy (53% [28-72%]) are not significantly different. CONCLUSIONS: Modern radiotherapy is a reasonable option for patients to consider for stage I NSCLC and is recommended for medically inoperable patients rather than supportive care or observation.

Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Lateral epicondylitis is a common condition for which botulinum toxin has been reported to have a therapeutic role in uncontrolled studies. OBJECTIVE: To determine if an injection of botulinum toxin is more effective than placebo for reducing pain in adults with lateral epicondylitis. DESIGN: Randomized, double-blind, placebo-controlled trial conducted from September 2002 to December 2004. SETTING: Outpatient clinics at a university hospital and a district hospital in Hong Kong. PARTICIPANTS: 60 patients with lateral epicondylitis. MEASUREMENTS: The primary outcome was change in subjective pain as measured by a 100-mm visual analogue scale (VAS) ranging from 0 (no pain) to 10 (worst pain ever) at 4 weeks and 12 weeks. All patients completed post-treatment follow-up. INTERVENTIONS: A single injection of 60 units of botulinum toxin type A or normal saline placebo. RESULTS: Mean VAS scores for the botulinum group at baseline and at 4 weeks were 65.5 mm and 25.3 mm, respectively; respective scores for the placebo group were 66.2 mm and 50.5 mm (between-group difference of changes, 24.4 mm [95% CI, 13.0 to 35.8 mm]; P < 0.001). At week 12, mean VAS scores were 23.5 mm for the botulinum group and 43.5 mm for the placebo group (between-group difference of changes, 19.3 mm [CI, 5.6 to 32.9 mm]; P = 0.006). Grip strength was not statistically significantly different between groups at any time. Mild paresis of the fingers occurred in 4 patients in the botulinum group at 4 weeks. One patient's symptoms persisted until week 12, whereas none of the patients receiving placebo had the same complaint. At 4 weeks, 10 patients in the botulinum group and 6 patients in the placebo group experienced weak finger extension on the same side as the injection site. LIMITATIONS: The trial was small, and most participants were women. The blinding protocol may have been ineffective because the 4 participants who experienced paresis of the fingers could have correctly assumed that they received an active treatment. CONCLUSIONS: Botulinum toxin injection may improve pain over a 3-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension.

Simple partial status epilepticus in Chinese adults.

Simple partial status epilepticus (SPSE) is uncommon compared with generalized tonic-clonic status epilepticus. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with this condition. We identified 32 patients above the age of 14 years with SPSE from a large urban hospital over an eleven-year period. Factors for poor outcome, defined as death or morbidity, were analyzed. The most common underlying causes were due to cerebrovascular disease (46.9%), CNS infection (15.6%), metabolic derangement (12.5%) and tumor (12.5%). At 30 days from the onset of seizures, 13(40.5%) patients had recovered fully and seven (21.9%) had died. Poor outcome was associated with the presence of an acute symptomatic injury.

Socio-economic status and patterns of care in lung cancer.

OBJECTIVE: This retrospective study aims to explore the associations between socio-economic factors and lung cancer management and outcomes in the Australian setting. METHODS: The study population consisted of patients who were living in the Northern Sydney Area Health Service (NSAHS) or South Western Sydney Area Health Service (SWSAHS) at the time of their lung cancer diagnosis in 1996. Data on patient demographics, tumour characteristics, management details, recurrence and survival were collected and compared between the two areas. Socio-economic status indicators of the two Area Health Services were obtained from the Australian Bureau of Statistics. RESULTS: There were 270 and 256 new cases of lung cancer identified in NSAHS and SWSAHS respectively. Patients in NSAHS were slightly older and there were more women. Based on the 1996 Census data, the population of NSAHS is more affluent, better educated and more likely to be employed compared with SWSAHS. The stage distributions and performance status of the two areas were similar. The utilisation rates of different treatment modalities in the two areas were similar except for chemotherapy. The five-year overall survival rate was 10.5% in NSAHS and 7.2% in SWSAHS (p=0.08). Comparison based on the SEIFA Index of Relative Socio-economic Disadvantage did not reveal significant differences. CONCLUSION: Patients with lung cancer had similar patterns of care and survival despite differences in socio-economic profiles between the two Area Health Services. IMPLICATION: There seems to be equity of access to lung cancer services between the two Area Health Services.