Intracerebral haemorrhage as a rare complication of HSV-1 meningoencephalitis: Case report and review of the literature

We present a case of herpetic meningoencephalitis confirmed by PCR in a 22-y-old male, with accompanying appearance of a large intracerebral haematoma as a complication. Despite the impressive imaging findings, the final outcome of the patient's progress was favourable.

Incidence and characteristics of peripheral neuropathy during oxaliplatin-based chemotherapy for metastatic colon cancer

AIM

The current prospective study sought to trace the incidence and severity of oxaliplatin-induced peripheral neuropathy (OXLIPN) and to determine its clinical and electrophysiological pattern.

PATIENTS AND METHODS

Twenty-five adult patients scheduled to be treated with 12 courses of the oxaliplatin-based regimen, FOLFOX-4, for metastatic colon cancer participated in this study. Patients were clinically and electrophysiologically monitored at baseline and followed-up during chemotherapy. The severity of OXLIPN was summarized by means of a modified Total Neuropathy Score (TNS).

RESULTS

Evidence of OXLIPN was disclosed in 16 of the 25 patients (64%). The mean TNS values for patients manifesting some grade of OXLIPN were 13.9 +/- 5.8 (range 7-28). All longitudinal comparisons concerning the motor conduction parameters failed to reach significance. By contrast, comparisons of the median changes at baseline and each of the follow-up studies revealed significant decrease in all sensory action potentials examined.

CONCLUSION

Our results indicate that the majority of patients treated with the FOLFOX-4 regimen would manifest an axonal, predominately sensory peripheral neuropathy, of mild to moderate severity.

Molecularly targeted therapies for dysimmune neuropathies

Conventional treatment options, including corticosteroids, intravenous immunoglobulin, or plasma exchange, often fail to treat dysimmune neuropathies, such as chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and monoclonal gammopathy with its subtypes. Therefore, a significant percentage of patients require adjunctive immunosuppressive therapies. Considering that even immunosuppressive agents often are ineffective and/or associated with significant toxicities, the need for the development of safe and effective new treatment options is rising. Currently, several monoclonal antibodies (MAbs) have been tested in open-label small-sized studies or even in single cases so as to establish future directions in the therapy of diseases of the peripheral nervous system (PNS). Rituximab, an MAb targeting against the B cell surface membrane protein CD20, is the most widely used and promising MAb for the treatment of dysimmune neuropathies, especially for those in which immunoglobulin M (IgM) autoantibodies are pathogenetically involved. The efficacy of alemtuzumab, bevacizumab, and etanercept to treat various forms of dysimmune neuropathies is currently under investigation. This review looks critically at recent developments in molecularly targeted therapies for dysimmune neuropathies and also highlights areas of future research to pursue.

Myasthenia gravis initially presenting with pseudo-internuclear ophthalmoplegia

Myasthenia gravis (MG) can rarely be manifested with ocular motility disturbances, simulating internuclear ophthalmoplegia. Pseudo-internuclear ophthalmoplegia (PINO) may occur during the course of MG, however, the initial presentation of MG with PINO in rather unlikely. We herein describe the case of a male patient who developed PINO, as an initial manifestation of MG.

Molecularly targeted therapies for malignant gliomas

This review critically evaluates current knowledge of molecularly targeted therapies of malignant gliomas.Various molecularly targeted single-agent therapies, including targeted therapies of growth and survival, have been evaluated in clinical trials but have failed to demonstrate a significant survival benefit compared with standard treatment regimens. The efficacy of multitargeted kinase inhibitors or combinations of single-targeted kinase inhibitors is a promising strategy, but requires additional clinical evaluation before definitive conclusions can be made. Important areas for further research include the assessment of serum or tissue biomarkers, the elucidation of prognostic molecular markers, and the determination of whether the mechanism of action of a drug is appropriate to the genetic alterations observed within individual tumors.

Recent advances relating to the clinical application of naked monoclonal antibodies in solid tumors

This review focuses on the recent advances in clinical data regarding antibody-based therapy in the management of solid tumors. We also discuss perspectives on antibody-based therapy in the future. Thorough understanding of the complex interactions between components of the immunological response has led to interest in the concept of immune-mediated therapy for solid tumors. Over the last few years, several humanized and chimeric monoclonal antibodies (MAbs) targeting human epidermal receptor 2 (HER2), epidermal growth factor receptor (EGFR), and vascular endothelial growth factor (VEGF) have been employed in treating solid tumors, including breast, colorectal, lung, head and neck, and gynecologic cancers. Trastuzumab, bevacizumab, cetuximab, and panitumumab are MAbs that are most widely used in clinical practice with acceptable rates of adverse events. Combination of MAbs with small-molecule inhibitors of the same pathway could potentially increase the efficacy and specificity of antibody-based treatment. Immune-mediated effects may be further exploited with the use of bivalent molecules.

Multiple sclerosis and reproductive risks in women

During the previous decades, women with Multiple Sclerosis (MS) were discouraged from having children, as pregnancy was deemed dangerous for pregnancy outcome and a contributing factor for exacerbation of MS. Current knowledge shows that women with MS are no more likely to have pregnancy or delivery complications compared to healthy women. Immunomodulatory therapies should be avoided during pregnancy and while breastfeeding. However, despite that it is still not recommended during pregnancy, Glatiramer acetate has fewer risks than the other MS drugs with respect to pregnancy outcome. IVIg treatment appears to be safe in unblinded studies and may be used after the first trimester to prevent the exacerbation of postpartum relapses. Gestation is a period of decreased risk for a relapse, whereas relapses are more common in the first six months after childbirth, compared to the pre-pregnancy period. Breastfeeding and epidural anaesthesia are not associated with increased incidence of post-partum relapses.

Neuromyelitis optica: a distinct demyelinating disease of the central nervous system

OBJECTIVES

We review and discuss the pathogenesis, epidemiology, diagnosis as well as recent advances in the treatment of NMO. We also highlight areas of future research.

METHODS

A review was carried out on reports drawn from MEDLINE until 2007.

RESULTS

Neuromyelitis optica (NMO) is a relative uncommon demyelinating disease of the central nervous system (CNS) that preferentially affects the optic nerves and spinal cord. NMO follows an unpredictable course, being either monophasic or relapsing. The relapsing form of NMO primarily affects women with onset varying from childhood to adults in their 40s or elderly. Until recently, NMO was considered to be a variant of multiple sclerosis. However, in contrast to multiple sclerosis, NMO attacks are not mediated by T cells but rather by B cells and NMO-immunoglobulin G antibodies that target aquaporin-4. Humoral immune mechanisms, including complement activation plays an important role in the pathogenesis of NMO. At present, parenteral corticosteroids are widely employed as first-line treatment of optic neuritis and myelitis attacks, whereas therapeutic plasmapheresis is applied in the case of corticosteroids failure. Various strategies for the prevention of NMO relapses have been employed in small case series with modest activity.

CONCLUSION

Recent advances in the clinical, neuroimaging, laboratory and pathological hallmarks have established that NMO is a distinct demyelinating disease of the CNS.

Co-occurrence of brain tumours and demyelination of the central nervous system: coincidence or interrelation?

The co-occurrence of a brain tumour and demyelinating disease of the central nervous system (CNS) constitutes a rare clinical entity. We herein report the incidence of meningioma and CNS non-specific demyelination in a patient with a 6-year history of operated brain tumour (meningioma). Our case bolsters the argument that in at least some cases, the occurrence of a brain tumour could predispose to CNS non-specific demyelination.

Effect of epoetin alpha therapy on cognitive function in anaemic patients with solid tumours undergoing chemotherapy

The primary aim of this study was to assess whether epoetin alpha (Ea) would improve cognitive performance in a group of anaemic cancer patients receiving chemotherapy. The secondary aim was to confirm the positive impact of Ea on haematological parameters, and quality of life (QOL). Fifty patients with solid tumours and haemoglobin (Hb) <11.0 g/dL received Ea 40,000 units once weekly for 12 weeks and were administered the Mini-Mental State Examination and the European Organization for Research and Treatment of Cancer (QLQ-C30) questionnaire prior to Ea therapy and at study completion. No clinically significant alterations were observed on cognitive function during Ea treatment. Changes in cognitive function were unrelated to Hb change and there were no significant differences in cognitive performance between Ea responders and non-responders. The analyses revealed clinically significant improvements in Hb levels, physical and role function, and clinically meaningful reductions in fatigue. Hb changes were significantly associated with the magnitude of improvement in QOL parameters. The lack of a clinical benefit in cognition observed in this study during Ea treatment may redirect the focus of research from enhancing to maintaining cognitive function, since stability in cognitive performance through time may be as well clinically important.

Bilateral drop foot secondary to a primary tumor in the conus medullaris

Intramedullary tumors of the spinal cord are rare neoplasms that can be associated with severe neurological and functional handicaps. To our knowledge, we describe for the first time the case of a male patient who developed bilateral drop foot as an initial manifestation of a primary tumor in the conus medullaris of the spinal cord, probably an astrocytoma.

Emotional distress in cancer patients at the beginning of chemotherapy and its relation to quality of life

PURPOSE

The present study sought to determine the prevalence of emotional distress and evaluate demographic and clinical factors related to anxiety and depression in treatment-naïve cancer patients at the beginning of chemotherapy. Another objective was to explore the associations between emotional distress and quality of life (QoL), an endpoint of great importance in current cancer care.

PATIENTS AND METHODS

Adult outpatients with a variety of cancer diagnoses were administered the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment of Cancer (EORTC QLQC30) questionnaire prior to the initiation of treatment.

RESULTS

A total of 265 patients took part in the study. A sizeable minority of our patients reported intense levels of anxiety (27.2%) and depression (19.6%). Patients without a partner, females, and patients with advanced disease or lower physician-rated performance status (PS) were more likely to experience clinically significant emotional distress. Levels of anxiety and mainly depression were negatively related to all QoL domains.

CONCLUSION

Our results indicate that a significant proportion of Greek cancer patients experience intense anxiety and depression prior to chemotherapy, and confirm the adverse impact of psychological morbidity on patients' QoL. Standardized and timely screening of emotional distress across all phases of cancer will help to effectively identify patients whose symptoms warrant attention. Future studies should continue to develop and evaluate rapid measures for detecting significant emotional distress in cancer patients, and to devise appropriate interventions to treat distress and enhance patients' QoL.

Painful limbs/moving extremities

Painful limbs/moving extremities (PLME) is a disorder characterized by spontaneous, complex, slow (1-2 Hz) involuntary toe or finger movements. The movements that can be bilateral or unilateral are usually accompanied by pain in the affected limbs. Painless variants are less common. PLME has been associated with peripheral and central nervous system disease although idiopathic cases have been reported. Its etiopathogenesis is unknown and treatment approaches remain largely empirical. Nerve blocks and botulinum toxin type A injections as well as oral medication have had some measure of success. Current theories suggest that central oscillator(s) at the spinal or supraspinal levels may be involved. Future research in PLME should include prospective electrophysiological and functional imaging studies as well as clinical trials with botulinum toxin injections and oral pharmacological agents.

Peripheral nerve damage associated with administration of taxanes in patients with cancer

Peripheral neuropathy is a well recognized toxicity of taxanes, usually resulting to dose modification and changes in the treatment plan. Taxanes produce a symmetric, axonal predominantly sensory distal neuropathy with less prominent motor involvement. A "dying back" process starting from distal nerve endings followed by effects on Schwann cells, neuronal body or axonal transport changes and a disturbed cytoplasmatic flow in the affected neurons is the most widely accepted mechanism of taxanes neurotoxicity. The incidence of taxanes-induced peripheral neuropathy is related to causal factors, such as single dose per course and cumulative dose and risk factors including treatment schedule, prior or concomitant administration of platinum compounds or vinca alcaloids, age and pre-existing peripheral neuropathy of other causes. The most reliable method to assess taxanes neurotoxicity is by clinical examination combined with electrophysiological evaluation. There is currently no effective symptomatic treatment for paclitaxel-associated pain, myalgias and arthralgias. Tricyclic antidepressants and anticonvulsants have been used as symptomatic treatment of neurotoxicity with some measure of success. Therefore, new approaches for prophylaxis against taxanes-induced peripheral neuropathy are needed. Several neuroprotective agents including, thiols, neurotrophic factors, and antioxidants hold promise for their ability to prevent neurotoxicity resulting from taxanes exposure. However, further confirmatory trials are warranted on this important clinical topic. This review critically looks at the pathogenesis, incidence, risk factors, diagnosis, characteristics and management of taxanes-induced peripheral neuropathy. We also highlight areas of future research.

A review on oxaliplatin-induced peripheral nerve damage

Platinum compounds are a class of chemotherapy agents that posses a broad spectrum of activity against several solid malignancies. Oxaliplatin (OXL) is a third-generation organoplatinum compound with significant activity mainly against colorectal cancer (CRC). Peripheral neuropathy is a well recognized toxicity of OXL, usually resulting in dose modification. OXL induces two types of peripheral neuropathy; acute and chronic. The acute oxaliplatin-induced peripheral neuropathy (OXLIPN) may be linked to the rapid chelation of calcium by OXL-induced oxalate and OXL is capable of altering the voltage-gated sodium channels through a pathway involving calcium ions. On the other hand, decreased cellular metabolism and axoplasmatic transport resulting from the accumulation of OXL in the dorsal root ganglia cells is the most widely accepted mechanism of chronic oxaliplatin-induced peripheral neuropathy (OXLIPN). As a result, OXL produces a symmetric, axonal, sensory distal primary neuronopathy without motor involvement. The incidence of OXLIPN is usually related to various risk factors, including treatment schedule, dosage, cumulative dose and time of infusion. The assessment of OXLIPN is primarily based on neurologic clinical examination and quantitative methods, such as nerve conduction study. To date, several neuroprotective agents including thiols, neurotrophic factors, anticonvulsants and antioxidants have been tested for their ability to prevent OXLIPN. However, the clinical data are still controversial. We herein review and discuss the pathogenesis, incidence, risk factors, diagnosis, characteristics and management of OXLIPN. We also highlight areas of future research.

Association of cigarette smoking and depressive symptoms in a forensic population

The link between mental health issues and smoking has been an important area of investigation. However, little is known about this association in a general adult, male forensic population. The aim of this study was to identify demographic and clinical (depression and anxiety) variables that predict smoking in a forensic population. A large cohort of 353 inmates in a high-security prison underwent a psychiatric interview, including administration of the Montgomery-Asberg Rating Scale for Depression (MADRS) and Hamilton's Rating Scale for Anxiety (HAM-A). Multiple regression analysis suggested that younger age and higher depression scores might predict the amount of daily smoking in this population. In contrast, anxiety symptoms were not an independent predictor for smoking in our study. These findings support the need for additional research to focus on those factors associated with smoking in forensic populations. Psychiatric screening for younger male individuals in forensic settings and targeted cognitive-behavioral interventions to treat depressed smokers may ameliorate the smoking abstinence rate in prisons.

A prospective study of familial versus sporadic Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is one of the most common neurodegenerative disorders. Most cases are sporadic but about 10-15% of patients have a positive family history of PD.

OBJECTIVE

To compare clinical phenotypes between familial (fPD) and sporadic (sPD) PD patients.

METHODS

Fifty-nine consecutive patients with at least one first-degree relative with PD were prospectively studied. After exclusion of 9 PD patients with positive family carrying known disease causing mutations, the remaining 50 were compared with 50 age- and sex-matched sPD patients.

RESULTS

Despite our methodological approach (strict diagnostic criteria, validated scales, structured interviews, multi- and two-member group formation and exclusion of patients with identifiable mutations) no major differences in the clinical phenotype between fPD and sPD were found.

CONCLUSION

Similar phenotypic characteristics of motor signs and symptoms suggest that at least the topography of the neurodegenerative insult leading to the parkinsonian clinical syndrome in fPD and sPD is similar. Similar etiologies are also suggested.

Clinical and electrophysiological features of peripheral neuropathy induced by administration of cisplatin plus paclitaxel-based chemotherapy

The current prospective study sought to trace the incidence and severity of cisplatin plus paclitaxel (DDP+P)-induced neuropathy and to determine its clinical and electrophysiological pattern. Furthermore, it was attempted to describe its evolution by following up the course of peripheral neuropathy (PN) during chemotherapy as well as 3 months after its discontinuation. Thirteen adult patients scheduled to be treated with six courses of cumulative DDP+P-based regimens for a non-myeloid malignancy participated in this study. These patients were clinically and electrophysiologically monitored at baseline, during chemotherapy and 3 months after its discontinuation. The severity of PN was summarized by means of a modified PN score. Evidence of PN was disclosed in nine of the 13 patients (69.2%). The mean PN score for patients that manifested some grade of PN was 17.3 +/- 6.1 (range 9-28). All longitudinal comparisons concerning the motor conduction velocities (MCV) variables failed to reach significance. By contrast, comparisons of the mean changes at baseline and each of the follow-up studies revealed a significant decrease in all sensory action potentials examined. The follow-up evaluation performed 3 months after the discontinuation of chemotherapy showed that the DDP+P-induced neuropathy persists and progresses over time. Our results indicate that the majority of patients treated with a DDP+P-based regimen at full dose intensities would manifest an axonal, predominately sensory PN, of mild to moderate severity, which would persist for several months after the discontinuation of chemotherapy.

Quetiapine successfully treating oculogyric crisis induced by antipsychotic drugs

We report two patients who developed persistent oculogyric crisis, obsessional thoughts and psychiatric symptoms after prolonged treatment with typical and atypical antipsychotics. Both our patients did not improve after withdrawal of these antipsychotics, but rather after quetiapine was administered.

Dynamic F wave study in patients suffering from peripheral arterial occlusive disease

OBJECTIVE

To prospectively detect significant transient F wave abnormalities obtained after exercise in patients with peripheral arterial disease (PAD) and to assess the potential diagnostic sensitivity of dynamic F wave study in such a context.

PATIENTS AND METHODS

A series of 40 electrical stimuli were delivered to the peroneal and the posterior tibial nerves of 25 patients with PAD in order to obtain F waves at rest and post-exercise. The following variables were estimated and the obtained pre- and post-exercise data were compared: F persistence, F wave latency, amplitude, duration and F chronodispersion. For each nerve studied, the minimum, average and maximum values were calculated. Conventional electrophysiological data were also collected pre- and post-exercise and the data obtained were also compared. Twenty-five healthy age-, gender- and height-matched individuals served as controls.

RESULTS

No evidence of conventional nerve conduction abnormalities was recorded either pre- or post-exercise in the group of patients. As regards the peroneal nerve, the significantly reduced F wave persistence (P = 0.007) and maximum F wave amplitude post- as opposed to pre-exercise (P = 0.05)- were the main findings to emerge. The average (P = 0.017) and the minimum duration (P = 0.005) of tibial F waves were also significantly increased post- compared with pre-exercise. Insignificant differences were observed between pre- and post-exercise neurophysiological and F wave values in the group of controls.

CONCLUSION

Given the observed absence of conventional neurophysiological abnormalities, the detection of dynamic F wave changes supports the view of an increased diagnostic sensitivity of this method in patients with mild PAD.

Efficacy of oxcarbazepine for prophylaxis against cumulative oxaliplatin-induced neuropathy

We conducted a randomized, open-label, controlled trial to assess the efficacy of oxcarbazepine for prophylaxis against oxaliplatin-induced peripheral neuropathy (OxIN). Thirty-two patients with colon cancer received 12 courses of the FOLFOX-4 regimen and were randomly assigned to receive oxcarbazepine (600 mg BID) or chemotherapy without oxcarbazepine. The incidence of OxIN was strikingly decreased in patients receiving oxcarbazepine (31.2% vs 75%). Oxcarbazepine may prevent OxIN symptoms. Further larger placebo-controlled trials are warranted to confirm our results.

The effect of stimulation technique on sympathetic skin responses in healthy subjects

The aim of this study was to collect normative data for sympathetic skin responses (SSR) elicited by electrical stimulus of the ipsilateral and contralateral peripheral nerves, and by magnetic stimulus of cervical cord. SSRs were measured at the mid-palm of both hands following electrical stimulation of the left median nerve at the wrist and magnetic stimulation at the neck in 40 healthy adult volunteers (mean age 52.2 ± 12.2 years, 19 males). The onset latency, peak latency, amplitude and area were estimated in “P” type responses (i.e., waveforms with a larger positive, compared to negative, component). SSR onset and peak latency were prolonged when the electrical stimulus was applied at the contralateral side (i.e., the SSR recorded in the right palm P < 0.001). The onset latency was similar on both sides during cervical magnetic stimulation. However, peak latency was faster on the left side (P < 0.03). Comparison of electrical and magnetic stimulation revealed that both the onset and peak latency were shorter with magnetic stimulation (P < 0.001). The latency of a SSR varies depending on what type of stimulation is used and where the stimulus is applied. Electrically generated SSRs have a longer delay and the delay is prolonged at the contralateral side. These factors should be taken into account when interpreting SSR data.

Factors associated with poor compliance of patients with epilepsy driving restrictions

The authors sought to identify factors associated with poor compliance with driving restrictions due to a diagnosis of epilepsy. They compared the demographic and clinical characteristics of 60 patients with epilepsy who, despite the authors' recommendation, continued to drive, with those of 60 age- and sex-matched epileptic patients who refrained from driving. The results showed that patients with epilepsy do not comply with driving restrictions, mainly for employment-related reasons.

Preventing paclitaxel-induced peripheral neuropathy: a phase II trial of vitamin E supplementation

A randomized, controlled trial was performed to assess the efficacy and safety of vitamin E supplementation for prophylaxis against paclitaxel-induced peripheral neuropathy (PIPN). Thirty-two patients undergoing six courses of paclitaxel-based chemotherapy were randomly assigned to receive either chemotherapy with vitamin E (300 mg twice a day, Group I) or chemotherapy without vitamin E supplementation (Group II). A detailed neurological examination and electrophysiological study was performed during and 3 months after chemotherapy. The severity of PIPN was summarized by means of a modified Peripheral Neuropathy (PNP) score. The incidence of neurotoxicity differed significantly between groups, occurring in 3/16 (18.7%) patients assigned to the vitamin E supplementation group and in 10/16 (62.5%) controls (P=0.03). The relative risk (RR) of developing PIPN was significantly higher in controls than in vitamin E group patients (RR=0.3, 95% confidence interval (CI)=0.1-0.9). Mean PNP scores were 2.25+/-5.1 (range 0-15) for patients in Group I and 11+/-11.63 (range 0-32) for those in Group II (P=0.01). Vitamin E supplementation was well tolerated and showed an excellent safety profile. This study shows that vitamin E effectively and safely protects patients with cancer from the occurrence of paclitaxel-induced peripheral nerve damage. A double-blind, placebo-controlled trial is needed to confirm these results.

Ulnar F wave generation assessed within 3 days after the onset of stroke in patients with relatively preserved level of consciousness

OBJECTIVE

The present study aimed to detect any significant changes of F wave variables associated with acute hemiparesis in a group of stroke patients with relatively preserved consciousness (Glascow Coma Scale (GCS) score 8 or higher) and to detect the possible clinical significance of F wave recording in acute stroke patients for diagnostic purposes.

PATIENTS AND METHODS

Thirty-two consecutive patients with mean age 65+/-10.6 years admitted with a diagnosis of acute ischemic or primary hemorrhagic stroke were studied. A series of 40 electrical stimuli were delivered to the ulnar nerve bilaterally in order to obtain F waves. F wave studies were performed within 3 days from stroke's onset. The following variables were estimated and then compared between affected and unaffected side: F persistence, F wave latency, amplitude, duration and chronodispersion. A group of 30 healthy age-matched subjects served as control.

RESULTS

F persistence was significantly lower in both affected and unaffected sides as compared to controls. There was no statistical differences of latency values between control and either side of the stroke' patients. A significant decrease of maximum F wave amplitude was detected in both affected and unaffected side as opposed to controls. Separate analysis of the subgroup of 15 patients with stroke and completely normal level of consciousness (GCS score 15) did not showed any significant differences of F wave variables in the affected or unaffected side compared with controls.

CONCLUSION

The F wave persistence is not expected to be suppressed in the first few days after stroke unless the level of consciousness is reduced. The routine F wave studies are not appropriate to evaluate the severity of motor deficit, at least in the immediate period after a stroke incident.

F wave study in amyotrophic lateral sclerosis: Assessment of balance between upper and lower motor neuron involvement

OBJECTIVE

We sought to record significant F wave variable changes in ALS patients having no advanced disease. Furthermore, an interpretation of these F wave abnormalities in the context of upper (UMN) and lower motor neuron (LMN) dysfunction was attempted.

METHODS

Standard motor and sensory conduction study was performed to the ulnar nerves of 23 patients with ALS (13 males and 10 females with mean age 67.2+/-5.3 years), having a clinically predominant LMN syndrome. A series of 40 electrical stimuli were also delivered to both their ulnar nerves in order to obtain F waves. The following F wave variables were estimated: F persistence, F wave latency, amplitude, duration and F chronodispersion. Twenty-three, age-and gender-matched healthy volunteers served as controls.

RESULTS

Both the distal and proximal ulnar a-CMAPs (P=0.001) and the MCV (P=0.014) values were significantly decreased in patients, than the controls. The sensory conduction study was normal. The ulnar F wave persistence in the ALS patients was significantly lower than that of the controls (P=0.0007). The mean (P=0.0001), minimal (P=0.0001) and maximal (P=0.0001) F wave latencies were significantly prolonged, the F wave amplitudes (P=0.0001) were significantly higher and the F wave chronodispersion (P=0.014) was significantly increased in the patients than the controls.

CONCLUSIONS

Significant F wave abnormalities occur in patients with ALS, even those patients having no advanced disease. Increased F wave amplitudes combined with low persistence is a pattern consistent with ALS.

SIGNIFICANCE

Our results show that patients with ALS having predominantly LMN involvement also have electrophysiological UMN dysfunction.

Lunar phases and seizure occurrence: Just an ancient legend?

The authors retrospectively reviewed all neurologic records of an emergency unit from 1999 to 2003 to identify a potential association between lunar phases and seizure occurrence. Overall 859 patients admitted for seizure occurrence were divided into the four quarters of the synodic month according to moon phases. A significant clustering of seizures around the full moon period was observed, supporting the ancient belief of periodic increased seizure frequency during full-moon days.

The significance of intact sympathetic skin responses in carpal tunnel syndrome

The current study aimed to investigate the impact of carpal tunnel syndrome (CTS) on sympathetic skin response (SSR) recorded from the median and ulnar territory. Thirty patients were studied and idiopathic CTS was documented in a total of 46 hands. These were classified, according to electrophysiological criteria, into two groups; a group of 31 hands with severe CTS and a group of 15 hands with mild/moderate CTS, and were compared with a group of 30 hands of age-matched controls. SSR was recorded simultaneously from the median and ulnar side of the palm following electrical stimulation at the wrist, in a mid-point between median and ulnar nerve. Latency, amplitude, habituation and the median-to-ulnar ratio were estimated. In all controls clear recordings of SSR were obtained. In the patient groups, absence of SSR was never observed either in mild/moderate or in the severe CTS hands. The mean SSR latency and amplitude values recorded from both the median and ulnar nerves did not significantly differ between mild/moderate or severe CTS hands and controls. Likewise, the median-to-ulnar ratio and habituation of SSR latencies and amplitudes did not significantly differ between groups. SSR does not seem to be a sensitive method for evidence of autonomic involvement in CTS, even in patients manifesting sudomotor or other autonomic symptoms. In the present setting, SSR appeared to be independent of somatic afferent function and the corresponding sensory action potentials.

A randomized controlled trial evaluating the efficacy and safety of vitamin E supplementation for protection against cisplatin-induced peripheral neuropathy: final results

AIM

A randomized, open label with blind assessment, controlled trial was performed to assess efficacy and adverse-event profile of vitamin E, given as supplementation for prophylaxis against cisplatin-induced peripheral neuropathy (CIPN).

PATIENTS AND METHODS

A total of 30 patients scheduled to receive six courses of cumulative cisplatin-based regimens were randomly allocated to treatment and control groups and were then studied by means of neurological examination and electrophysiological study. Patients assigned to group I (n=14) orally received vitamin E at a daily dose of 600 mg/day during chemotherapy and 3 months after its cessation were compared to patients of group II (n=16), who received no vitamin E supplementation and served as controls. The severity of neurotoxicity was summarized by means of a modified Peripheral Neuropathy (PNP) score.

RESULTS

The incidence of neurotoxicity differed significantly between groups, occurring in 3/14 (21.4%) of patients assigned to the vitamin E supplementation group and in 11/16 (68.5%) of controls (p=0.026). The relative risk (RR) of developing neurotoxicity was significantly higher in case of controls, RR=2.51, 95% C.I.=1.16-5.47. Mean PNP scores were 4.99+/-1.33 for patients of group I and 10.47+/-10.62 for controls, (p=0.023). None of the adverse events or deaths occurred, were judged as likely to be related to the vitamin E supplementation.

CONCLUSION

Vitamin E effectively and safely protects patients with cancer from occurrence of cisplatin neurotoxicity.

A case of fatal progressive neuropathy. Delayed consequence of multiple bites of a non-venomous snake?

Neurotoxicity is a common feature of the acute syndrome of systemic snake envenomation. In this report a patient with delayed onset of neurological manifestations after multiple bites of a non-venomous snake is described. The neurological cascade consisted of segmental painful muscle spasms presented several days after the snake bites, which gradually subsided and within a month was followed by muscle weakness in the legs. The latter progressed to flaccid quadriplegia with additional respiratory and autonomic failure leading to death after total disease duration of 5.5 months. The possibility that this unique neurological syndrome of fatal progressive neuropathy could be caused by either tetanus or an immune reaction initiated by snakebites is discussed.

Wilson's disease and benign epilepsy of childhood with centrotemporal (rolandic) spikes

Cases with a clinical and electroencephalographic phenotype of benign epilepsy of childhood with centrotemporal spikes (BECTS) in association with a proven organic brain lesion have rarely been reported. To our knowledge, we herein describe for the first time a patient with Wilson's disease who subsequently manifested BECTS. Our case bolsters the argument that in at least some cases, BECTS is associated with organic brain disease.

Headache characteristics and brain metastases prediction in cancer patients

The aim of this study was to evaluate the headache and other neurological symptoms and signs as guide predictors for the occurrence of brain metastases in cancer patients. We prospectively studied 54 cancer patients with newly appeared headache or with a change in the pattern of an existing headache during the recent months. All patients completed a questionnaire regarding headache's clinical characteristics and existence of accompanying symptoms. They also underwent a detailed neurological, ophthalmologic examination and brain neuroimaging investigation. Brain metastases were diagnosed in 29 patients. Univariate regression analysis showed an association between occurrence of brain metastases and nine clinical symptoms or signs. Multivariate regression analyses emerged only four of them as significant independent predictors. These were: bilateral frontal-temporal headache, more pronounced on the side of metastasis in cases of single metastases, with duration > or =8 weeks, pulsating quality and moderate to severe intensity (OR: 11.9; 95% CI. 2.52-56.1), emesis (OR: 10.2; 95% CI. 2.1-55.8), gait instability (OR: 7.4; 95% CI. 1.75-33.9) and extensor plantar response (OR: 12.1; 95% CI. 2.2-120.7). In conclusion, all cancer patients who manifest the above independent clinical predictors should be highly suspected for appearance of brain metastases and therefore should be thoroughly investigated.

Suicidal ideation in prisoners: risk factors and relevance to suicidal behaviour. A prospective case-control study

OBJECTIVE

To investigate risk factors for suicidal ideation (SI) in prisoners, as well as the prediction of suicidal behaviour by SI.

METHOD

Participants were recruited from the all-male,adults', high security prison of Patras, Greece. Sixty-seven prisoners who expressed SI were evaluated using a structured interview, Hamilton's Rating Scale for Anxiety (HAMA) and the Montgomery-Asberg Rating Scale for Depression (MADRS). Sixty-seven control prisoners without SI, matched for age, nationality and penal status were evaluated using the same structured interview and rating scales. All participants were followed-up prospectively for 12 months after their initial assessment and any acts of self-destructive behaviour were recorded.

RESULTS

Independent significant risk factors for SI in prisoners were the family history of suicidal behaviour (OR = 56.34, 95% CI = 4.23-750.1, p < 0.002), history of psychiatric hospitalisation (OR = 7.18, 95% CI = 1.83-28.16, p < 0.005), and higher scores in the MADRS (p < 0.03) and HAMA (p < 0.03) scales. During the follow-up period, suicidal behaviour (suicide attempt or self-mutilation) was observed in 12 (17.9%) inmates with SI, as opposed to none of the controls (p < 0.0001).

CONCLUSION

A family history of suicidal behaviour, history of psychiatric hospitalisation and symptoms of anxiety or depression were independent risk factors for SI in prisoners. Inmates with SI had a higher risk for self-destructive acts at follow-up. Inmates with SI are a high-risk group for future self-destructive acts, so special precautions designed to reduce this risk are warranted.

The impact of paclitaxel or cisplatin-based chemotherapy on sympathetic skin response: a prospective study

The current study aimed to assess the viability of sympathetic sudomotor fibers in cancer patients treated with cisplatin or paclitaxel-based chemotherapy and to ascertain whether this method could contribute to the diagnostic sensitivity of conventional techniques. Sympathetic skin response (SSR) from the hand and sole of 23 cancer patients (nine females and 14 males, mean age 62.4 +/- 10.5 years) was recorded unilaterally before and after chemotherapy with six courses of cumulative cisplatin or paclitaxel containing regimens. Clinical and electrophysiological data were also collected and correlated with the SSR results. Twenty-three healthy subjects served as controls. SSR abnormalities were only present in patients with evidence of peripheral neuropathy assessed by conventional nerve conduction techniques. Three patients had absent SSR in the upper limb whilst six patients had absent SSR both in the upper and lower limbs. In the upper limb, the mean SSR latency was not significantly altered through time (P = 0.086). In the lower limb the mean delay from baseline to follow-up was significantly changed (P = 0.029). In patients, the mean SSR latency was significantly prolonged compared with controls in both upper limb (P = 0.001) and lower limb (P = 0.000). SSR abnormalities were strongly related to sensory conduction abnormalities as detected by conventional techniques (r = 0.39, P = 0.004). Our results showed that SSR does not seem to add to the diagnostic sensitivity of conventional techniques in chemotherapy-induced neuropathy. However, its role in the disclosure of small fibers neuropathy abnormalities is worth considering. Further studies are warranted to address this important issue.

Sympathetic skin response in patients with peripheral arterial occlusive disease

OBJECTIVE

The current study aimed to assess the viability of sympathetic sudomotor fibers in patients suffering from mild peripheral arterial occlusive disease (PAD).

METHODS

Sympathetic skin response (SSR) from the hand (electrical stimulation) and sole (electrical and magnetic stimulation) of 25 patients with PAD (19 males and 6 females with mean age 62.7 +/- 10.2 years) was recorded unilaterally depending on the side of the affected limb (18 right side, 7 left side). Electrophysiological data were also collected and correlated with the SSR results. Twenty-five, age- and gender-matched healthy volunteers served as controls.

RESULTS

No evidence of nerve conduction abnormalities was recorded from the group of patients. Intact SSR recordings were obtained from the upper limb of patients. Nine patients (36%) had absent SSR in the lower limb following electrical stimulation, whilst the same 9 patients had absent SSR following magnetic stimulation. Significant differences occurred between groups in the SSR latency scores recorded from the lower limb. Following electrical stimulation the mean SSR latency in patients was significantly prolonged, compared to that of controls (P = 0.000), whilst the same applied following magnetic stimulation (P = 0.000). There was no correlation between SSR abnormalities and nerve conduction measurements. The manifestation of intermittent claudication at a walking distance of 250 m was strongly correlated with absent lower limb SSR (r = 0.71, P = 0.035).

CONCLUSIONS

SSR abnormalities appeared to be an early and independent finding of neural impairment in our patients.

SIGNIFICANCE

SSR study, performed at an early stage of PAD may prove useful in differentiating PAD-induced neuropathy from other neuropathic processes.

Level of consciousness as a conditioning factor of F wave generation in stroke patients

OBJECTIVE

The current study aimed to investigate whether the level of consciousness influenced the F wave generation, as an independent factor.

METHODS

Forty three patients with acute stroke were divided according to their level of consciousness in two groups; to those with Glasgow scale (GCS) score 3-7 indicating coma (group I) and those with GCS score 8-15 (group II). A series of 40 electrical stimuli were delivered to the ulnar nerve bilaterally in order to obtain F waves. The following variables were estimated and then compared between groups: F persistence, F wave latency, amplitude and duration. All studies were performed within 3 days from the onset of the stroke symptoms.

RESULTS

The main finding to emerge was the significantly reduced F wave persistence in the group of patients with low GCS score as opposed to patients allocated in the group with GCS score 8-15. This result is referred to F waves obtained from both the affected and unaffected limb. F wave minimum latency was also prolonged in the group with low GCS score, whilst the comparison of all other F wave variables revealed no significant differences between groups I and II. F wave persistence measurements did not differ between the affected and unaffected sides. Stroke location and type (ischemic or hemorrhagic) were not associated with alterations of F wave measurements.

CONCLUSIONS

Our results on stroke patients suggest that generation of F waves, expressed by the F wave persistence is associated with the level of consciousness.

SIGNIFICANCE

F wave study may be useful as an objective measure in documenting the severity of consciousness impairment.

Quetiapine in the treatment of focal tardive dystonia induced by other atypical antipsychotics: a report of 2 cases

The authors report 2 patients with schizophrenia who developed focal tardive dystonia secondary to treatment with atypical antipsychotics (risperidone, olanzapine). When quetiapine was gradually introduced and other antipsychotics were discontinued, these patients experienced remarkable and sustained improvement of their dystonic symptoms, without loss of psychotic symptom control. The mechanism by which quetiapine may improve tardive dystonia caused by other atypical antipsychotics is unclear. Due to its receptor and pharmacologic profile, quetiapine is the atypical antipsychotic that is most similar to clozapine (without its hematologic side effects), which leads the authors to consider it for the treatment of tardive movement disorders.

Paclitaxel plus carboplatin-induced peripheral neuropathy. A prospective clinical and electrophysiological study in patients suffering from solid malignancies

OBJECTIVE

The current study intended to determine the incidence, severity and reversibility of paclitaxel plus carboplatin (CP)-induced peripheral neuropathy (CPPN) and to describe its clinical and electrophysiological features.

PATIENTS AND METHODS

We prospectively studied 21 adult patients scheduled to be treated with 6 courses of cumulative carboplatin plus paclitaxel (CP) regimens for a non-myeloid malignancy. They were followed-up by neurological examination and electrophysiological study during chemotherapy and 3 months after its discontinuation. The severity of neurotoxicity was assessed by means of a modified peripheral neuropathy (PNP) score.

RESULTS

Evidence of CPPN was recorded in 14 of the 21 patients (66.6 %). The sensory symptoms were present in the lower limbs first and then involved the upper limbs. No statistical significance, concerning the changes from baseline to subsequent mean scores in all motor conduction parameters examined,was revealed. By contrast, comparisons of the mean changes at baseline and each of the follow-up studies showed significant decrease in all sensory action potentials examined. The mean PNP scores for patients that manifested some grade of neurotoxicity were 17.9 +/- 9.8. The followup data 3 months after the discontinuation of chemotherapy showed that the CP-induced neuropathy was at least partially reversed.

CONCLUSIONS

CP-induced neuropathy was symmetrical, distal and predominantly sensory in character, though minor to moderate motor signs were only evident in severely affected patients. Reversibility of CP-induced neuropathy was partially observed after the suspension of chemotherapy.

The effect of depression on motor function and disease severity of Parkinson's disease

OBJECTIVES

Approximately 40% of patients with Parkinson's disease (PD) experience symptoms of depression. Our aim was to evaluate the effect of depression on disease severity, motor function and other phenotypic characteristics of PD.

PATIENTS AND METHODS

We studied 32 PD patients with major depression (PD-D) according to the DSM-IV criteria and 32 PD patients with no depression (PD-C) matched for gender, age of onset and duration.

RESULTS

Major depression in PD patients was associated with increased disease severity, poorer motor function and worse performance in the activities of daily living as measured by UPDRS scores. Furthermore, there was an association of depression with the severity of bradykinesia and axial rigidity.

CONCLUSIONS

Depression in PD can have a profound negative impact on a patient's sense of wellbeing and motor functioning. Therefore, PD patients should be routinely and carefully screened for the presence of depression and appropriate management should be considered. Larger studies on the subject are warranted.