ABSTRACT
Intravascular lymphoma is an uncommon subtype of B-cell lymphoma with neoplastic cells limited to the lumen of small blood vessels. We report a case of a 52-year-old man who presented with constitutional symptoms and rapidly progressive dementia. He was found to have diffuse leptomeningeal and faint parenchymal enhancement on magnetic resonance imaging and was subsequently diagnosed with intravascular lymphoma following a brain biopsy. He responded remarkably well to systemic and intrathecal chemotherapy. The diagnosis and treatment of intravascular lymphoma have been guided by a few case reports and are largely based on expert opinion.
ABSTRACT
OBJECTIVE: Prior to establishing the correct diagnosis, patients with psychogenic nonepileptic seizures (PNES) frequently endure significant costs and morbidities associated with utilization of health care resources. In this study of the US veterans population, we aimed to investigate for potential changes in health resource utilization before versus after video-EEG (VEEG) confirmation and disclosure of the PNES diagnosis. METHODS: We prospectively studied 65 veterans with VEEG confirmed diagnosis of PNES, and followed their health care utilization during the subsequent 3 years after the diagnosis. Primary outcomes entailed comparing the quantities of post-VEEG outpatient visits and diagnostic procedures versus those during the 3-year span prior to the diagnosis. Secondary outcome involved specifically the measures of seizure-related antiepileptic drug (AED) use from time points before and after VEEG. RESULTS: Within the category of non-psychiatric outpatient visits, we observed significant post-diagnostic decrease in the utilization of PNES-related outpatient visits (p < 0.001). Contrastingly, we found significant post-diagnostic increase in the utilization of non-PNES-related outpatient visits (p = 0.004). When examining exclusively for psychiatric outpatient visits, we further observed a trend toward increased attendance of outpatient visits (p = 0.056) after VEEG. Utilization of diagnostic procedures was not significantly different before versus after VEEG (p = 0.293). 52.3% of the patients were prescribed AEDs for seizure-related purpose during the one-year period leading up to VEEG. By comparison, only 7.7%, 12.3%, and 10.8% of the patients were still on AEDs for seizure-related purpose at the one-year, two-year, and three-year time points after VEEG, respectively. CONCLUSION: We demonstrate new evidence that VEEG confirmation of the PNES diagnosis among US veterans can significantly reduce key measures of non-psychiatric/PNES-related resource utilization, while also potentially associating with appropriate enhancement of psychiatric outpatient visits. However, our results suggest that within this patient population, further efforts are necessary to address heightened demands for non-PNES-related outpatient visits after VEEG.
Subject(s)
Health Resources/statistics & numerical data , Seizures/diagnosis , Seizures/economics , Adult , Age of Onset , Anticonvulsants/therapeutic use , Cost of Illness , Electroencephalography , Female , Health Resources/economics , Humans , Male , Mental Disorders/complications , Middle Aged , Prospective Studies , Psychophysiologic Disorders/diagnosis , Seizures/therapy , Socioeconomic Factors , Treatment Outcome , United States , VeteransABSTRACT
During an outcomes study of spasticity treatment at a developmental center for 62 residents with profound intellectual disabilities, either botulinum toxin A (BTX-A), intrathecal baclofen (ITB), or both were recommended with physical and occupational therapy. Conservators consented to BTX-A more than ITB (p = .021). Court-appointed conservators were more likely to provide consent for treatment than family members (p = .026). Nonparents consented more than parents (p = .009). Finally, Caucasian conservators were more likely to consent to treatment than African American conservators (p = .036), but ethnicity of the resident did not influence consent. Gender of resident or conservator did not influence rate of consent. This report highlights disparities in surrogate consent giving for individuals with intellectual disabilities and indicates a need for more research to ensure that this vulnerable population has access to appropriate treatments.
