Suthipun Jitpimolmard

Long term results of botulinum toxin type A (Dysport) in the treatment of hemifacial spasm: a report of 175 cases

OBJECTIVE To describe the long term efficacy and side effects of the treatment of hemifacial spasm with Dysport and to evaluate two different sites of injection to hopefully reduce side effects. METHODS This study was designed as a prospective descriptive study. Injections were made subcutaneously around the eye. Peak improvement was subjectively assessed by using a visual analogue scale and reported in percentages (0–100%). Duration of improvement was assessed subjectively and reported in months. RESULTS Of 175 cases, 17 were lost to follow up and were excluded. 855 treatments were injected in the remaining 158 patients with a median of 4 treatments. The response rate was 97%. Of 855 treatments, the adjusted mean peak and duration of improvement was 77.2 (95% confidence interval (95%CI) 74.7–79.4)% and 3.4 (95%CI 3.2–3.6) months respectively. In 158 patients (complete group), the long term results from the first to the 12th treatment showed that the mean peak improvement ranged from 72.70 to 80.10% and the duration of improvement was 2.60 to 3.71 months. It remained constant throughout (p=0.40, p=0.87 respectively). The most common side effect was ptosis. Of the 158 patients, 21 completed 12 treatments (subgroup). A separate analysis of this group disclosed a mean peak and duration of improvement from the first to 12th treatments ranging from 70.00 to 78.10% and 2.65 to 4.31 months respectively. Analysis of variance with repeated measures showed no significant variation of peak and duration of improvement over the first to the 12th treatments (p=0.38, p=0.38 respectively). Only 3% of the treatments were unsuccessful but responded to subsequent treatments. The incidence of ptosis was reduced from 27.17% to 9.68% by moving the injection site to the lateral part of orbital orbicularis oculi without any loss of efficacy. The yearly cost of Dysport is considerably less than Botox. CONCLUSION This study is the first to show, in detail, the long term results of treatments of hemifacial spasm with Dysport. The efficacy is constant throughout the first to 12th treatments in both the complete group and subgroup. Ptosis can be reduced by moving the injection site further up to the lateral part of the orbital orbicularis oculi. The efficacy of Dysport is comparable with Botox® in long term follow up.

Peripheral neuropathy associated with Castleman's disease.

Four patients with polyneuropathy complicating the plasma cell variant of Castlemans disease (angiofollicular lymph node hyperplasia) are described. The neuropathy was predominantly motor and severely disabling. Vasculopathy, papilloedema, organomegaly, endocrinopathy, oedema and paraproteinaemia were variably present in these patients. Sural nerve biopsy showed changes of both demyelination and axonal loss. Capillary proliferation and endothelial hypertrophy in the epineurium and endoneurium, similar to that seen in affected lymph nodes, suggested that a diffuse vasculopathy may contribute to the neuropathy. Serum antibody activity against a variety of neural antigen preparations was not detected in any of the patients. Two untreated patients died. Substantial improvement in the neuropathy occurred in the two patients treated with cyclophosphamide and prednisolone.

Seizures in nonketotic hyperglycaemia

Dear Sir, The association between focal seizures and hyperglycaemia was first reported in 19651. The disorder is characterized by hyperglycaemia, no ketoacidosis, full consciousness (or minimal depression of sensorium) and focal seizures. We report 21 patients, who presented with seizures and nonketotic hyperglycaemia (NKH). This is a large case series. The aim of this report is to study clinical and laboratory characteristics of seizures in NKH. A retrospective study was done in a teaching hospital. Inclusion criteria were (1) hyperglycaemia (plasma glucose more than 11.11 mmol/l), (2) seizures, and (3) seizure stopping after control of the hyperglycaemia. Patients with seizures explained by causes other than hyperglycaemia were excluded from the study. Of the 21 patients, 9 were men (43%) and 12 were women (57%) who developed seizures and NKH (23 events). One patient had three events. Six patients had a previous history of diabetes mellitus (DM). Fifteen patients had no previous history of DM. They presented with seizures and NKH, and were diagnosed with DM in the index admission. Of the 21 patients, 3 were DM type 1 (14.3%) and 18 were DM type 2 (85.7%). The average duration of seizures before admission was 5 days (range 1–14 days). The average duration of seizures in each episode was 3 minutes (range 1–5 minutes). Total of 22 events (95.65%) were partial seizures, and 1 event was an unclassified tonic-clonic seizure. Among the 22 partial onset seizures, 14 were epilepsia partialis continua, 6 became secondarily generalized tonic-clonic seizures, and 2 were complex partial seizures (CPS). In all 20 events of partial seizures without CPS, seizures started in one extremity or the face: 14 started in an upper extremity, 5 in the face, and 1 in a lower extremity. Partial seizures started slightly more often on the left side (12 cases) than the right side (8 cases). At the time of the seizure, the average plasma glucose value was 32.61 mmol/l (range 16.11–61.33 mmol/l). The average calculated serum osmolarity was 302 mOsm/l (range 288–323 mOsm/l). When the seizures stopped, the average plasma glucose value was 11.3 mmol/l (range 4.11–21.67 mmol/l). Neurologic manifestations, particularly seizures, may provide the first clinical clue to the presence of NKH. Focal motor seizures are the most common type2. However, seizures in NKH are still not fully appreciated by physician and patient. Our patients took an average of 5 days before they got the correct diagnosis and treatment. Knowledge of this condition may shorten the time to diagnosis and decrease the discomfort of patients. Every patient who presents with seizures especially focal seizures should have an immediate determination of plasma glucose levels. Seizures in NKH happen equally in both sexes. In 15 of the 21 patients (71.4%), seizures were the earliest manifestation of DM and led to discovery of DM in these patients. Most of patients had type 2 DM. Although 3 of the 21 patients had type 1 DM, none of them had ketoacidosis during the seizure. This finding may be explained by the fact that ketosis has an anticonvulsant action, due to intracellular acidosis increasing glutamic acid and decarboxylase activity leading to increased levels of GABA3. Epilepsia partialis continua was the most common type (60.87%) of seizure in our series, as previously reported2. Interestingly, we found 2 (8.7%) of our patients presented with CPS. Our finding confirmed previous reports of CPS induced by hyperglycaemia4. The mechanism of seizures in NKH is still debated. The possible mechanisms are hyperglycaemia or hyperosmolarity, a low level of gamma aminobutyric acid (GABA), and focal ischaemia. Each mechanism, considered alone, is unsatisfactory. Mean plasma glucose value in our report was 32.61 (16.11–61.33 mmol/l), and osmolarity ranged from normal to a moderate value (288–323 mOsm/l). Almost all of our seizures in NKH patients have plasma osmolarity less than the classical diagnostic level (320 mOsm/l) of NKH. In addition, mean plasma glucose ranged from normal to hyperglycaemia (4.11–21.67 mmol/l) when seizures stopped. So, the explanation of hyperglycaemia or hyperosmolarity alone is unsatisfactory. In addition, the Krebs cycle in NKH is inhibited, GABA metabolism is increased and the levels may be decreased, thus lowering the threshold for seizure activtiy3, 5.

Clinical factors predictive of encephalitis caused by Angiostrongylus cantonensis.

Angiostrongylus cantonensis is mainly caused eosinophilic meningitis in humans, whereas a minority of patients develop encephalitic angiostrongyliasis (EA). EA is an extremely fatal condition, and the clinical factors predictive of EA have never been reported. A comparison study was conducted in a hospital situated in an endemic area of Thailand. We enrolled 14 and 80 angiostrongyliasis patients who developed encephalitis and meningitis, respectively. Logistic regression analysis was used to assess the clinical variables predictive of encephalitis. Age (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 1.05-1.42), duration of headache (adjusted OR, 1.26; 95% CI, 1.03-1.55), and fever > 38.0 degrees C (adjusted OR, 37.05; 95% CI, 1.59-862.35) were identified as statistically significant factors for EA prediction. Elderly patients with angiostrongyliasis experiencing fever and prolonged headaches were at the highest risk of developing EA.

Kluver–Bucy syndrome after mycoplasmal bronchitis

Kluver-Bucy syndrome is a rare neurobehavioral condition characterized by visual agnosia, excessive oral tendencies, hypermetamorphosis, placidity, altered sexual behavior, and changes in dietary habits. This description of a 14-year-old boy presenting with complete Kluver-Bucy syndrome after Mycoplasma pneumoniae bronchitis is the first such case report. MRI revealed left temporal horn dilation and asymmetry of both temporal lobes. We hypothesize that the pathophysiology of our case is immune-mediated damage by M. pneumoniae resulting in vasculopathy.

Prediction of seizure control in non-ketotic hyperglycemic induced seizures

BackgroundTo study the factors predictive for seizure control in non-ketotic hyperglycemic induced seizures (NKHS).MethodsWe studied 21 patients who were clinically diagnosed as NKHS at Khon Kaen University hospital, Thailand. Multiple linear regression analysis was used to identify the factors predictive for seizure control.ResultsMost patients had no previous history of diabetes and presented with repetitive partial seizures. The mean number of seizure attacks was 45 times prior to admission. The average duration to terminate seizure was 36 hours and significantly predicted by frequency of seizures (estimate 0.9, p value 0.013).ConclusionFrequency of seizures is the only predictive factor for the success of seizure control in NKHS.

Peripheral eosinophilia as an indicator of meningitic angiostrongyliasis in exposed individuals.

The diagnosis of meningitic angiostrongyliasis (MA) is based on clinical criteria. A lumbar puncture is used as a diagnostic tool, but it is an invasive procedure. The blood eosinophil levels are also assessed and used in the diagnosis of this disease. We enrolled 47 patients with serologically proven MA and 131 controls with intestinal parasite infections. An absolute eosinophil count model was found to be the best marker for MA. An eosinophil count of more than 798 cells led to sensitivity, specificity, positive predictive and negative predictive values of 76.6%, 80.2%, 58.1% and 90.5%, respectively. These data support the use of testing for high blood eosinophil levels as a diagnostic tool for MA in individuals that are at risk for this disease.

Predictive risk factors of seizure-related injury in persons with epilepsy

OBJECTIVE The clinical risk factors for seizure-related injuries (SRI) in adult persons with epilepsy (PWE) were studied and analyzed to develop a predictive model. METHODS We enrolled 300 consecutive cases from three epilepsy clinics in Northeast, Thailand. Subjects were eligible if reported to have at least one seizure attack during the past 12 months. Face-to-face questionnaire was used to evaluate SRI, baseline characteristics and other seizure-related variables. RESULTS There were 247 and 91 PWE who met a criterion and had SRI, respectively. By multivariate logistic regression method, GTC seizure type, having history of seizure attacks at least 12 times/year, and daytime seizure were significant risk factors of having SRI with odds ratio of 2.376, 2.460, and 3.562, respectively. We developed the predictive model for having SRI in PWE and it gave 90.3% sensitivity and 46.7% specificity on the occurrence of SRI. The estimated probability of SRI can be found online at http://sribykku.webs.com/. CONCLUSIONS The significant predictive factors for SRI in PWE were the occurrence of GTCs, seizures at least 12 times/year or daytime seizures. Clinicians or PWE can easily evaluate the risk of having SRI in individuals by the online predictive model.

How Can Clinicians Ensure the Diagnosis of Meningitic Angiostrongyliasis

Meningitic angiostrongyliasis (MA), caused by Angiostrongylus cantonensis, is often diagnosed by clinical criteria alone, because the confirmative serologic tests are not always available in the rural endemic areas. In this study, we evaluated the relationship between various clinical parameters of MA and the sero-positivity to sort out the predictive parameters to ensure the diagnosis. We enrolled consecutive adults in whom MA had been clinically diagnosed, who had serologic results for A. cantonensis, and negative serologic results for Gnathostoma spinigerum. There were 75 eligible patients; 26 (34.7%) and 49 (65.3%) patients who had negative and positive serologic tests for A. cantonensis, respectively. Baseline characteristics and laboratory results were comparable between sero-positive and -negative groups. Only the cerebrospinal fluid (CSF) eosinophil counts of 40% or higher was significantly predictive for positive serologic test with the adjusted odds ratio of 4.970 (95% confidence interval of 1.337-18.477). In diagnostic facilities in the endemic areas with the limited availability of serologic tests, clinicians can ensure the diagnosis of MA by using CSF eosinophil level.

A real life clinical practice of neurologists in the ambulatory setting in Thailand: a pragmatic study

The burden of neurological disorders is high in developing countries. Real life data from neurologists as to how they practice in Thailand are limited in literature. Practices of neurologists in a university hospital clinical setting in Thailand were studied. A prospective study was performed at the ambulatory neurology clinic, Khon Kaen University Hospital, between 1 February and 31 October 2009. The following data were recorded: numbers of patients, characteristics of patients, consultation notes, and time spent for each patient. There were three neurologists, each of whom ran one afternoon clinic, once a week. There were 6137 visits during the 9 months, with an average of 681 visits per month. The total number of patients was 2834. The three most common diseases were cerebrovascular diseases (33%), epilepsy (16%), and movement disorders (non-Parkinson’s disease, 12%). Neurologists spent an average of 6.34 minutes per patient. In conclusion, neurologists in medical schools have limited time to take care of each patient. Several strategies are needed in medical education and neurology training to improve the quality of care.