Hearing loss after lumbar puncture.

We report a 63-year-old man who developed transient acute on chronic hearing loss after a lumbar puncture performed to investigate raised intracranial pressure. He was subsequently found to have stenosis of the distal left transverse sinus, which was treated with stenting.

Predicting HIV disease progression in children using measures of neuropsychological and neurological functioning. Pediatric AIDS clinical trials 152 study team.

BACKGROUND: Neuropsychological testing and 2 measures of neurological status, cortical atrophy, and motor dysfunction were assessed for their usefulness in predicting human immunodeficiency virus (HIV) disease progression in infants, children, and adolescents who participated in Pediatric AIDS Clinical Trials Group Protocol 152 (PACTG 152). METHODS: A cohort of 722 antiretroviral therapy-naive children with symptomatic HIV infection were assessed at study entry and at later intervals. Assessments included neurodevelopmental testing, neuroradiologic imaging, and neurological examination of motor function. CD4 cell count and plasma RNA viral load also were measured. RESULTS: Children with the lowest neuropsychological functioning (IQ < 70) at baseline had the highest risk for later HIV disease progression (56%), compared with those with borderline/low (IQ = 70-89) functioning (26%), or with average or above (IQ > 90) functioning (18%). This was also true of week 48 neuropsychological functioning. Motor dysfunction (especially reduced muscle mass) at entry also predicted disease progression. Furthermore, motor dysfunction and week 48 neuropsychological functioning provided predictive information beyond that obtainable from surrogate markers of HIV disease status (eg, CD4 count, HIV RNA level). Children with cortical atrophy also were at higher risk for later disease progression, but when CD4 count and RNA viral load were known, cortical atrophy information provided no additional predictive information. CONCLUSIONS: Measures of neuropsychological and motor function status provide unique information regarding pediatric HIV disease progression. As such, these findings have important implications for predicting long-term outcomes (eg, longevity) in pediatric patients.

Early presentation of type 2 diabetes mellitus in young New Zealand Maori.

For 51 (5%) of the 1052 Maori patients registered with the Northland New Zealand (NZ) Diabetes Service, an initial diagnosis of diabetes was made before they had reached 30 years of age. We reviewed epidemiological and clinical data of this patient group. A total of 28 patients (55%) have type 2 diabetes, 18 (35%) have type 1 diabetes and for five patients, we were unable to determine the type of diabetes. The majority have positive family histories of diabetes (83%). The average age at diagnosis was 12.4 years for type 1 and 19.1 years for type 2 diabetes. Mean duration of diabetes and mean current HbA1c were not statistically different between the two groups, yet microalbuminuria or nephropathy was present in 62% of type 2 patients, but only 18% of the type 1 group. These statistics show that a significant number of Northland NZ Maori develop type 2 diabetes at an earlier age than expected and have a high incidence of renal complications. These findings contrast with previous New Zealand studies on the incidence of diabetes in young Maori, but are similar to those of recent overseas studies of ethnic groups with a high incidence of diabetes.

Interpreting treatment differences when patients drop out of a clinical trial.

Clinical trials are the standard for identifying new drugs for the treatment of disease, but results are dependent on patient compliance. The success of treatments for HIV disease in particular may be judged in part by their effect on immunologic, virologic, or clinical measures collected on patients at regular predefined intervals. If patients drop out of a trial before study completion, the analysis of the repeatedly collected parameters needs to be undertaken and interpreted with care. The authors recommend using graphic techniques to assess the impact of the missing data on the profiles of the parameters over time. To assess treatment differences, a variety of simple tests are proposed that allow different assumptions to be made regarding the reasons for the incomplete data. A case study is presented providing an analysis of CD4 data from the Pediatric Aids Clinical Trials Group (PACTG) Protocol 051, in which only 52% of the patients completed the study while remaining on treatment; younger patients with lower CD4 counts were more likely to stop treatment earlier. This type of systematic missing data can lead to incorrect conclusions regarding different treatment effects on CD4 counts. With the data of PACTG 051, however, regardless of the methodology used, no treatment differences were found. Inconsistent conclusions would have indicated the need for more sophisticated statistical techniques to adequately test for treatment differences.

Anterior opercular syndrome, caused by herpes simplex encephalitis.

Bilateral frontal and parietal opercular lesions cause a syndrome characterized by paralysis of the masticatory, facial, pharyngeal, and tongue muscles (the anterior opercular syndrome). The anterior opercular syndrome can occur in patients with herpes simplex encephalitis (HSE), but in most of these patients the diagnosis of HSE was not confirmed. We describe the anterior opercular syndrome in four patients with HSE. In two of these patients, the anterior opercular syndrome dominated the clinical picture, but in the other two patients it was overshadowed by other manifestations of HSE. The diagnosis of HSE was confirmed by detection of herpes simplex virus (HSV) DNA in the CSF (two patients), culture of the HSV from a brain biopsy (one patient), and elevated HSV antibody titers in the CSF (one patient). Our patients made a partial recovery. Acute onset of weakness of masticatory, facial, pharyngeal, and glossal muscles, accompanied by fever, headache, and partial motor seizures of the face should suggest HSE.