Late deterioration after decompression illness affecting the spinal cord.

A former amateur diver presented with a progressive paraparesis. Thirteen years previously he had developed acute spinal cord dysfunction immediately after dry hyperbaric exposure. He had completely recovered motor function in the intervening period. No alternative reason for the later decline emerged from detailed investigation.

Audit of the management of patients with refractory epilepsy.

Achieving rational management for patients with refractory epilepsy can be difficult. We audited our management of 55 patients with refractory epilepsy by comparing two 3-month periods each 9 months apart. Despite attempts to rationalize antiepileptic drug therapy, a smaller proportion of patients were managed with monotherapy by the second analysis (16% vs 22%); however fewer patients were taking three or more AEDs (28% vs 43%). A substantial impact on seizure frequency was made in only six patients whilst 22 patients had a significant deterioration in seizure number (P = 0.005). Monitoring of AED levels was of little value with only six clinical decisions based on 305 AED levels performed at a cost of 2525 pounds. The newer AEDs accounted for a disproportionate expenditure (65% of the total AED cost in the second 3-month period) considering their lack of therapeutic impact. We confirm the need for audit in this patient group to ensure that pre-defined targets are met.

Impact of lamotrigine on patients with refractory epilepsy: the Leicester experience.

We prospectively monitored our experience of lamotrigine as add-on therapy in 45 patients with refractory epilepsy. Nine patients (20%) withdrew from treatment due to adverse drug reactions and five patients (11%) withdrew because of a deterioration in seizure frequency. A further 17 patients (38%) showed little (< 25%) reduction in seizure number, eight patients (18%) showed a 25-50% reduction whilst 15 patients (33%) had a 50% or greater reduction in seizure number (P = 0.002). Lamotrigine was of greater benefit in patients with tonic-clonic seizures (seven of fourteen [50%] showed a > 50% seizure reduction; P = 0.01) than in patients with complex partial seizures (seven of 22 [32%] showed a > 50% seizure reduction; P = 0.02). Despite a high withdrawal rate due to ADRs, lamotrigine proved of significant benefit to one-third of our study group.

Status epilepticus: management and outcome of 107 episodes.

Morbidity and mortality from status epilepticus might be reduced by attention to recommended management protocols. We studied our experience of 107 episodes of status epilepticus in 43 patients over a 5-year period. Overall mortality was 2% and permanent sequelae developed in 11 cases (10%). Although hospital admission was rapid, treatment could be initiated more quickly in the community (P < 0.0001). However treatment given before admission did not significantly reduce the duration of status (median difference 38 minutes, 95% C.I., 24 to 55 minutes). Diazepam was the first line treatment in 98 episodes, chlormethiazole and phenytoin were used in 27 and 18 episodes, respectively. Paraldehyde was used in 12 episodes. Midazolam was used in the intensive care setting in two cases. Clonazepam, lorazepam, lignocaine and phenobarbitone were not used at all. There was a marked failure to adhere to the recommended management protocols.

Pregnancy, epilepsy, management and outcome: a 10-year perspective.

We analysed the management and outcome of 348 pregnancies in 207 women with epilepsy from 1977 to 1981 and 1987 to 1991. Outcome was successful in 88%. There was a marked change in anticonvulsant prescribing away from phenobarbitone and phenytoin towards carbamazepine and sodium valproate but a large number of patients (24%) were treated with two or more anticonvulsants in the second cohort despite a move towards monotherapy. A significant reduction in congenital malformation (4.8%), spontaneous abortion (6.9%) or low birth weight babies (9.4%) was not seen. Until experience is gained with the newer agents, monotherapy remains of major importance in the management of the pregnant woman with epilepsy.

Vigabatrin: a three year clinical analysis.

The effect of introducing vigabatrin into the management of 57 patients with severe epilepsy is reported. Overall it reduced fit frequency by 50% or more in 36% of our patients. We found it to be more effective than previously reported for primary tonic-clonic seizures, but less so for complex partial seizures. Fewer of our patients withdrew from treatment due to adverse drug reactions than in earlier studies.

Spinal cord compression due to metastatic spread from a primary carcinoid tumour of the thymus.

We reported a patient with spinal cord compression due to the metastatic spread of a primary carcinoid tumour of the thymus to bone. Prompt surgical decompression with local radiotherapy led to good functional recovery and survival at 2 years without further recurrence.

The apomorphine test in parkinsonian syndromes.

The dopamine receptor agonist apomorphine has been used successfully to treat on-off swings in Parkinson's disease. Its value as a predictor of dopa responsiveness in idiopathic Parkinson's disease (IPD) was assessed and its potential role in differentiating IPD from the Parkinsonian plus syndromes (PPS) of multisystem atrophy, progressive supranuclear palsy and olivopontocerebellar atrophy was investigated. The response to an injection of apomorphine was observed in 20 patients with IPD and eight with PPS after being off levodopa for 12 hours. Patients were reassessed after taking levodopa for one month. Nineteen of the 20 patients (95%) with IPD showed a positive response to apomorphine and 18 (90%) to oral levodopa. In the PPS group, two patients (25%) responded to the apomorphine injection but not to oral levodopa. Apomorphine produced severe drowsiness in the PPS patients. It is suggested that the test can predict dopa responsiveness in IPD and may be of help in confirming a doubtful diagnosis. It has potential value in differentiating IPD from PPS.

Dietary modification of Parkinson's disease.

To investigate the efficacy of a low-protein diet suitable for long-term use, and to observe the effect in a double-blind manner of re-introducing large neutral amino acids or an inactive placebo amino acid, eight patients with 'on-off' phenomenon were given a low-protein diet suitable for long-term use, and then the diet was supplemented with large neutral amino acids (LNAA) or placebo in a double-blind crossover trial. Five patients had improved Parkinsonian disability on a low-protein diet compared to normal diet. On supplementing the diet with LNAA or placebo, three subjects' Parkinson's disease was significantly better on placebo and there was a trend towards improvement on placebo noticed subjectively by seven patients; however, there was no overall significant difference in disability measured by mobility diaries. Thus, we have been unable to show that the improvement on a low-protein diet is due to a reduction in LNAA, rather than a placebo effect, possibly due to the paucity of subjects; however, the patients' identification of the LNAA supplement suggests that it is a genuine effect.

Multiple sclerosis associated with trismus.

This report describes the case history of a middle-aged lady who presented with symptoms and signs over one year leading to a diagnosis of multiple sclerosis. During one of her relapses, she developed trismus--an association that has not been described before in multiple sclerosis.

Multiple sclerosis associated with water intoxication.

We present a case of well documented multiple sclerosis which presented with the syndrome of inappropriate antidiuretic hormone secretion, following an exacerbation of the disease. This is a poorly documented association.

Severe ocular side effects of perhexilene maleate: case report.

We report a case of perhexilene maleate (PEXID) toxicity in which the presenting feature was loss of vision secondary to chronic papilloedema. Vortex keratopathy similar to that seen in amiodarone keratopathy was present, and corneal and conjunctival biopsy findings are presented. To our knowledge this is the first case report of a keratopathy occurring in perhexilene toxicity. After withdrawal of the drug the papilloedema and keratopathy subsided, but some visual deficit remains. The properties of perhexilene maleate and other amphiphilic drugs are described, and the possible aetiology of vortex keratopathy is discussed.

Controlled trial of plasma exchange in acute inflammatory polyradiculoneuropathy.

A randomised controlled trial of exchange versus no exchange was conducted to find out whether plasma exchange would be useful in acute inflammatory polyradiculoneuropathy. It was calculated that 15 patients would be required in each group to demonstrate a worthwhile improvement in functional ability 1 month after completion of treatment. Treatment comprised five exchanges in 10 days (55 ml plasma/kg body weight/exchange). Both groups received normal supportive care and were followed up periodically for a year. Overall the treated group showed a slight but not significant benefit (p greater than 0.05); at two weeks' follow-up of patients admitted to the trial within 14 days of onset of neuropathic symptoms, p = 0.07. These results do not provide grounds for recommending plasma exchange for the treatment of severe AIP.

Neurosyphilis in the Leicester area.

Twenty patients with neurosyphilis are reviewed. They were gathered over a 15-year period during which the overall incidence was 0.18 per 100,000, though fewer cases appeared in the latter half of the study. The commonest presentation was with mental symptoms and classical forms of neurosyphilis were rarely seen. No patient presented with epilepsy. There is a case for the more selective use of serological testing.