Rasmussen encephalitis: Incidence and course under randomized therapy with tacrolimus or intravenous immunoglobulins

Purpose: Rasmussen encephalitis (RE) leads to progressive tissue and function loss of one brain hemisphere and often intractable epilepsy. This is the first randomized prospective treatment trial in RE. Methods: Germany‐wide, patients with suspected recent‐onset RE were recruited and if eligible randomized to tacrolimus or intravenous immunoglobulins (IVIGs). A loss of motor function or hemispheric volume by ≥15% (in patients >12 years at disease onset: ≥8%) led to study exit. Untreated patients served as a historical control group. Key Findings: Over 6.3 years, 21 patients with recent‐onset RE were identified. Sixteen were randomized to tacrolimus (n = 9) or IVIG (n = 7). Immunotreated patients had a longer “survival” than the historical controls. Neither treatment was more efficacious than the other. Two tacrolimus patients experienced serious adverse events. No immunotreated but several untreated patients developed intractable epilepsy. No patient with refractory epilepsy became treatment‐responsive under immunotherapy. Significance: The countrywide incidence rate of diagnosed RE is estimated as 2.4 cases/10⁷ people ≤ age 18/year. Treatment with tacrolimus or IVIG may slow down tissue and function loss and prevent development of intractable epilepsy. However, immunotherapy may “arrest” patients in a dilemma state of pharmacoresistant epilepsy but too good function to be offered functional hemispherectomy. These compounds may therefore contribute to the therapeutic armamentarium for RE patients without difficult‐to‐treat epilepsies.     

Finding on brain MRI mimicking focal cortical dysplasia in early Rasmussen's encephalitis: a case report and review

Introduction  

Rasmussen's encephalitis (RE) is one of the important causes of refractory seizure. The most impressive clinical manifestation of RE is epilepsia partialis continua (EPC). Others include progressive hemiparesis and neuropsychological deterioration. Currently, the best approach to RE is hemispherectomy.     

Treatment of deep vascular orbital malformations

Objective

In this article, we discuss the clinical features and endovascular and/or surgical treatment of deep vascular orbital malformations.

Methods

We report on our treatment of 58 cases of vascular malformations of the orbit between 1991 and 2008.

Results

Arterial low flow lesions, such as cavernomas (n = 44) were the most common finding. These were treated by complete excision. High flow lesions such as angiomas were less common (n = 4). These were treated by the endovascular and/or surgical approach. Venous flow lesions appear as distensible lesions (n = 3) or non-distensible anomalies (n = 4). Deep venous lesions (n = 7) should be treated if they cause severe pain, progressive proptosis, motility disturbances or visual deterioration. No flow lesions include lymphangiomas (n = 3). Surgery may be helpful in specific cases with intracystic haemorrhage and progressive proptosis. Patients with severe visual deterioration do not improve, whereas all other symptoms are potentially reversible.

Conclusions

Treatment of vascular malformations is required in case of progression of symptoms. In cases of visual deterioration, we generally favour early treatment. The least invasive surgical approach, tailored to the individual patient, should be chosen.     

Treatment of sleep disorders may improve fatigue in multiple sclerosis

Objective

In a previous polysomnographic cross-sectional study we found a significant relationship between sleep disorders and multiple sclerosis (MS) related fatigue. The purpose of this open follow-up observation was to compare the impact of treatment of sleep disorders on MS related fatigue measured with the Modified Fatigue Impact Scale (MFIS).

Methods

Non-randomized follow-up observation: treated versus untreated patients, subgroups according to compliance with sleep medical treatment recommendations (univariate, multivariate analysis, multiple logistic regression). 66 MS patients were followed after polysomnography, 49 patients with relevant sleep disorders and 17 without.

Results

Mean MFIS scores decreased from 41.2 to 26.2 (p = 0.025) in patients with good compliance (GC; n = 18), from 42.4 to 32.1 (p = 0.12) in patients with moderate compliance (MC; n = 12), and from 41.6 to 35.5 (p = 0.17) in non-compliant patients (NC; n = 17). Mean MFIS values increased in patients without sleep disorders from 22.9 to 25.4 (NSD; n = 12, p = 0.56). In multiple logistic regression, treatment of sleep disorders predicted decrease of MFIS-values (GC versus NSD odds ratio 13.4; p = 0.015; 95% confidence interval (CI) 1.7–107.2, MC versus NSD odds ratio 13.8; p = 0.028; 95% CI 1.3–143.3).

Conclusions

Sleep medical treatment may improve MS related fatigue when patients adhere to treatment recommendations.     

Atypical Rasmussen’s encephalitis treated with temporal lobectomy

Rasmussen’s encephalitis is characterized by seizures, progressive neurological deterioration and chronic inflammation of the brain. It typically presents in childhood and requires anatomic or functional hemispherectomy for seizure control. Here, we report an adult woman who presented with new onset, medically refractory seizures that were not progressive. The patient underwent a right anterior temporal lobectomy. The pathologic samples were consistent with Rasmussen’s encephalitis. The patient remained seizure free until her last follow-up at 2 years. This is an example of unique adult onset Rasmussen’s encephalitis, suggesting that this encephalitis represents a wide spectrum of presentations rather than a specific disease.     

Usefulness of stereotactic biopsy and neuroimaging in management of HIV-1 Clade C associated focal brain lesions with special focus on cerebral toxoplasmosis

Background

Focal brain lesions (FBL) in HIV/AIDS frequently pose a diagnostic dilemma as the etiology varies from infective (tuberculoma, toxoplasmosis and tuberculous abscesses) to neoplastic lesions like lymphoma. For determining etiology, advanced neuroimaging techniques, serological and molecular biological tests have been evolved with varying sensitivities/specificities. Stereotactic biopsy (STB) of the lesions is reserved for lesions unresponsive to appropriate therapy.

Objective and methods

In this study, the diagnostic yield of neuroimaging [cranial CT (n = 25), MRI (n = 24), and Th201/99Tc SPECT scan (n = 18)] is compared with histopathological diagnosis obtained by STB (n = 21) or autopsy (n = 4) in 25 HIV-1 subtype C seropositive individuals with FBL identified by neuroimaging with special reference to cerebral toxoplasmosis in an eighteen month study period (2006–2007).

Results and conclusion

Cerebral toxoplasmosis was the most frequent cause of FBL (21/25, 84%), followed by one case each of tuberculoma, progressive multifocal leukoencephalopathy (PML), primary central nervous system lymphoma (PCNSL) and measles inclusion body encephalitis (MIBE), the last two diagnosed at autopsy. Of the 21 cases of cerebral toxoplasmosis, definitive diagnosis with histopathological confirmation was available in 14/21 (66.6%), with indirect evidence suggesting probable toxoplasmosis in seven, all of whom responded to antitoxoplasma therapy. CT and MRI had comparable specificities (75%), while MRI had marginally higher sensitivity (85% versus 80.9%) in detecting multiple lesions. The positive predictive value of both CT and MRI was identical (94.4%), suggesting that CT maybe a cost effective screening tool in resource restricted settings, for evaluating FBL. Sensitivity of 99Tc SPECT scan for diagnosing inflammatory lesions was 75% but failed to differentiate PCNSL from toxoplasmosis. This study is the first of its kind from India analyzing FBL with specific focus on cerebral toxoplasmosis in the setting of HIV-1 subtype C.     

Feasibility, reliability and validity of the Dutch translation of the Anxiety, Depression And Mood Scale in older adults with intellectual disabilities

Background

The informant-based Anxiety, Depression And Mood Scale was translated into Dutch and its feasibility, reliability and validity in older adults (aged ≥ 50 years) with intellectual disabilities (ID) was studied.

Method

Test-retest (n = 93) and interrater reliability (n = 83), and convergent (n = 202 and n = 787), discriminant (n = 288) and criterion validity (n = 288) were studied. Convergent and criterion validity were studied for the Depressed mood and General anxiety subscales. Subgroups based on level of ID and autism have been made to study the criterion validity. Psychiatric diagnoses based on the PAS-ADD Interview were used as gold standard.

Results

All subscales had good internal consistency (α ≥ 0.80), excellent test-retest reliability (ICC ≥ 0.75) and good interrater reliability (ICC ≥ 0.74), except for the Social avoidance subscale (ICC = 0.57). The Depressed mood subscale showed low correlation (r = 0.44) with the self-report Inventory of Depressive Symptomatology, high correlation with the informant-report Signalizing Depression List for people with ID (r = 0.71) and no correlation with the PAS-ADD's sleep disorders subscale (r = 0.15). Its sensitivity ranged from 73 to 80%, and its specificity from 71 to 79%. The General anxiety subscale showed low correlation with the self-report scales: Glasgow Anxiety Scale (r = 0.37) and Hospital Anxiety and Depression Scale (r = 0.41), and no correlation with the sleep disorder subscale (r = 0.02). Its sensitivity ranged from 67 to 100%, and its specificity from 48 to 81%.

Conclusions

The Dutch translation of the ADAMS is reliable and sufficiently valid to screen for anxiety and depression in older people with ID.     

Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction

Immune and inflammatory mechanisms are detected in a subgroup of treatment resistant hospitalized affective and schizophrenic spectrum disorder patients. We analysed albumin, IgG, IgA, IgM, oligoclonal IgG and specific antibodies in paired cerebrospinal fluid (CSF) and serum samples. Numerical and graphical interpretation of CSF protein data was performed by Reibergrams with a new CSF statistics tool for nonlinear group analysis with reference to a large control group (n = 4100). In 41% of the psychiatric patients (n = 63) we observed CSF pathologies: 14% displayed intrathecal humoral immune responses, 10% slightly increased CSF cell counts (5-8/μL) and 29% had moderate blood-CSF barrier dysfunctions, in 24% as the only pathological sign with normal IgG, IgA and IgM concentrations in CSF (p = 0.9 testing the null hypothesis for intrathecal synthesis with reference to Qmean of the reference group). In the group of affective (n = 24) spectrum disorders 20% displayed a systemic immune reaction as detected by oligoclonal IgG. CSF analysis and interdisciplinary clinical approach revealed 6% of psychiatric patients likely to represent a virusspecific, bacterial or autoimmune associated disorder with CNS involvement. Elevated CSF neopterin concentration in 34% of the patients was interpreted as an increased release from astrocytes or from other glia cells. The low level immune response and barrier dysfunctions are discussed on the base of a mild encephalitis pathomechanism in subgroups of psychiatric patients. CSF analysis is shown to be a useful diagnostic tool for differential diagnosis in psychiatric diseases.     

Long-Term Outcomes of Hemispheric Disconnection in Pediatric Patients with Intractable Epilepsy

Background and Purpose

Hemispherectomy reportedly produces remarkable results in terms of seizure outcome and quality of life for medically intractable hemispheric epilepsy in children. We reviewed the neuroradiologic findings, pathologic findings, epilepsy characteristics, and clinical long-term outcomes in pediatric patients following a hemispheric disconnection.

Methods

We retrospectively studied 12 children (8 males) who underwent a hemispherectomy at Asan Medical Center between 1997 and 2005. Clinical, EEG, neuroradiological, and surgical data were collected. Long-term outcomes for seizure, motor functions, and cognitive functions were evaluated at a mean follow-up of 12.7 years (range, 7.6-16.2 years) after surgery.

Results

The mean age at epilepsy onset was 3.0 years (range, 0-7.6 years). The following epilepsy syndromes were identified in our cohort: focal symptomatic epilepsy (n=8), West syndrome (n=3), and Rasmussen''s syndrome (n=1). Postoperative histopathology of our study patients revealed malformation of cortical development (n=7), encephalomalacia as a sequela of infarction or trauma (n=3), Sturge-Weber syndrome (n=1), and Rasmussen''s encephalitis (n=1). The mean age at surgery was 6.5 years (range, 0.8-12.3 years). Anatomical or functional hemispherectomy was performed in 8 patients, and hemispherotomy was performed in 4 patients. Eight of our 12 children (66.7%) were seizure-free, but 3 patients with perioperative complications showed persistent seizure. Although all patients had preoperative hemiparesis and developmental delay, none had additional motor or cognitive deficits after surgery, and most achieved independent walking and improvement in daily activities.

Conclusions

The long-term clinical outcomes of hemispherectomy in children with intractable hemispheric epilepsy are good when careful patient selection and skilled surgical approaches are applied.     

Patterns of care and survival of glioblastoma patients: A comparative study between 2004 and 2008 in Lyon,France

Introduction

The treatment of glioblastomas (GBMs) has changed significantly since 2005. However, the extent to which this change has improved overall survival (OS) of patients treated outside clinical trials remains to be determined.

Methods

We compared the patterns of care and OS of all GBM patients diagnosed in 2004 (n = 105) and in 2008 (n = 130) in our center.

Results

Younger patients (aged < 70 years) diagnosed in 2008 received temozolomide radiochemotherapy as the initial treatment and bevacizumab at recurrence more frequently than those diagnosed in 2004 (69% vs 26% P < 10⁻⁴ and 41% vs 3%, P < 10⁻⁴, respectively). Elderly patients (aged ≥ 70 years) diagnosed in 2008 received an oncological treatment (radiotherapy and/or chemotherapy) more frequently than those diagnosed in 2004 (67% vs 38%, P = 0.006). The patients diagnosed in 2008 had longer OS than those diagnosed in 2004 (10.5 months vs 5.3 months, P = 0.001). This finding was true for both younger and elderly patients (15.3 months vs 8.9 months, P = 0.02 and 6.4 months vs 3.2 months, P = 0.0002, respectively) and when considering only IDH1 wild-type patients (8.9 months vs 5.3 months, P = 0.004).

Conclusion

In our center, the change in the patterns of care for GBMs between 2004 and 2008 has been associated with a significant improvement in OS.     

Endovascular treatment of distal intracranial aneurysms with Onyx 18/34

Objective

Surgical clipping and coil embolization of distally located intracranial aneurysms can be challenging. The goal of this study was to assess the feasibility, safety and efficacy of treatment of distal aneurysms with the liquid embolic agent Onyx 18/34.

Methods

Sixteen patients were treated with Onyx 18/34 for distally located aneurysms in our institution between March 2009 and September 2012. The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in which coiling was considered impossible.

Results

Of the 16 patients, 12 presented with subarachnoid and/or intracerebral hemorrhage. Median aneurysm size was 4.6 mm. Aneurysm locations were as follows: Posterior inferior cerebellar artery (n = 5), distal anterior inferior cerebellar artery (n = 3), distal pericallosal (n = 3), distal anterior cerebral artery (n = 3), lenticulostriate artery (n = 1), and anterior ethmoidal artery (n = 1). There were 4 mycotic aneurysms. Complete aneurysm obliteration was achieved in all 6 patients with available angiographic follow-up. There was only 1 (6.3%) symptomatic complication in the series. There were no instances of reflux or accidental migration of embolic material. Favorable outcomes were noted in 82% of patients at discharge. Two patients with mycotic aneurysms died from cardiac complications of endocarditis. No aneurysm recanalization or rehemorrhage were seen.

Conclusion

Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms.     

Electro-clinical features and magnetic resonance imaging correlates in Menkes disease

Background: Epilepsy is an early and important feature in Menkes disease (MD), an X-linked recessive neurodegenerative disorder of childhood with defect in copper metabolism. There are only few reports on the electro-clinical and magnetic resonance imaging correlates in Menkes disease. The current study describes the electro-clinical features in MD in relation with the structural findings on MRI. Patients and Methods: Six patients from five families were evaluated between 2005 and 2011. Their diagnosis was based on the characteristic morphological features, microscopic evidence of pili torti and low copper and ceruloplasmin levels. All the patients underwent MRI and EEG as part of the evaluation. Results: All patients had classical form of MD with typical morphological features. All but one patient had refractory seizures. Seizure types included multifocal clonic seizures (n = 3), myoclonic jerks (n = 4) and tonic spasms (n = 1). EEG was markedly abnormal in all except in the patient without clinical seizures. While focal epileptiform discharges predominated before six months of age modified hypsarrhythmia was characteristically noted thereafter. MR Imaging revealed abnormalities in all patients, with cerebral atrophy and delayed myelination being the most common observations. Other features noted were subdural effusion (n = 3), leukoencephalopathy (n = 3) and basal ganglia signal changes (n = 1). Follow up imaging in three patients showed resolution of white matter signal intensity changes. Conclusions: Electro-clinical features in Menkes disease are age dependent and evolve sequentially. White matter changes coincided with acute exacerbation of seizures. There was fair correlation between the electro-clinical features and structural findings on MRI.     

Modulation of the mineralocorticoid receptor as add-on treatment in depression: A randomized, double-blind, placebo-controlled proof-of-concept study

Preclinical and clinical studies have suggested a role of the mineralocorticoid receptor (MR) in the response to antidepressants. We tested in a proof-of-concept study whether adding fludrocortisone (an MR agonist) or spironolactone (an MR antagonist) accelerates onset of action and improves efficacy of escitalopram in patients with major depression.We included 64 in- and outpatients with major depression (Hamilton Depression Scale-17 score > 18) in a double-blind, randomized, placebo-controlled trial. Patients were randomized in a 2:2:1 fashion to fludrocortisone (0.2 mg/d, n = 24) or spironolactone (100 mg/d, n = 27) or placebo (n = 13) for the first 3 weeks during a 5-week treatment with escitalopram.No differences in mean HAMD change scores and in time to response emerged between treatments. However, among the responders, patients treated with fludrocortisone responded faster (Breslow test, p = 0.05). The mean number of days to response was 16.0 ± 2.6 days vs. placebo 22.2 ± 2.0 vs. spironolactone 22.6 ± 2.3 (F = 3.78, p = 0.03). In the whole group, plasma cortisol increased during spironolactone and decreased during fludrocortisone treatment (F = 2.4, p = 0.04). In patients treated with fludrocortisone, non-responders had elevated cortisol values compared to responders throughout the study period (F = 5.1, p = 0.04).Stimulation of MR with fludrocortisone as adjunct to escitalopram accelerated the response in the group of responders while no effect emerged in the sample as a whole. A larger randomized controlled trial is warranted.     

Outcome of surgical decompression of spinal mass lesions in non-Hodgkin's lymphoma and plasmacytoma

Objective

Surgical treatment for spinal mass lesions due to non-Hodgkin's lymphoma (NHL) or plasmacytoma is necessary only in rare instances. The purpose of this study was to investigate long-term outcome and quality of life of surgery combined with postoperative chemotherapy or radiochemotherapy.

Methods

The data of patients, who underwent spinal surgery for mass lesions in a 10-year periods were reviewed, identifying 10 patients with a histopathological diagnosis of NHL or plasmacytoma. Functional outcome were assessed by the Karnofsky Performance Score (KPS), quality of life by the Short Form-36 (SF-36) Health Survey Questionnaire, and pain by the Visual Analog Scale (VAS).

Results

Clinical presentations included pain (n = 10), paresis (n = 5), and sensory deficits (n = 5). Surgical treatment included removal of the mass lesion (total, n = 5; subtotal, n = 5) for decompression, interbody fusion (n = 3), and corporectomy followed by stabilization (n = 1). Histopathological findings revealed NHL in five patients and plasmacytoma/multiple myeloma in five other patients. Postoperatively, all patients underwent chemotherapy or radiochemotherapy. Mean follow-up time was 38 months. At the last follow-up, 2 patients had succumbed to progression of disease. Pain intensity remained significantly reduced as compared to preoperatively (p = 0.049). The KPS was 90–100% in five patients still alive, 70% in two, and 60% in one. SF-36 subscores were lower as compared to age-matched healthy controls.

Conclusions

This retrospective study shows that surgical decompression of spinal mass lesions is a valuable option in selected patients with NHL or plasmacytoma to improve neurological deficits and control pain. Long-term outcome after postoperative adjuvant therapy confirms prolonged stability of quality of life.     

Demographic,circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage

Background

Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before.

Objective

For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH.

Methods

We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n = 338) or naSAH (n = 46) on clinical and radiological criteria. PMH (n = 32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared.

Results

Aneurysmal SAH occurred most often from 6 am to 12 pm (p < 0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p = 0.008) and smoking (p = 0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p = 0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p < 0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p = 0.0159).

Conclusion

Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.     

Les atteintes neurologiques au cours du xeroderma pigmentosum

Introduction

Xeroderma pigmentosum (XP) is an autosomal recessive disease characterized by abnormal sensitivity to sunlight which results in pigmentary changes, telangiectases, keratoses and eventually carcinomata. Additional neurological complications can be associated. The aim of our study was to analyze particularities of neurological abnormalities of Tunisian patients.

Method

We conducted a retrospective study in 62 patients suffering from XP included during the period 1992-2007. Patients were aged from 1 to 64 years (mean age: 17.6 ± 11.4 years). Thirty patients were female and 32 were male. The patients had severe (n = 16), variant (n = 15) and moderate (n = 31) XP.

Results

Neurological abnormalities were observed in 21 patients (33.9%). Mental retardation was observed in 15 of the 21 patients, pyramidal syndrome in five, cerebellar syndrome in two, extrapyramidal syndrome in two, microcephalia in two, choreoatetosis in three cases and a peripheral neuropathy in eight. No neurological disorder was observed in the XP-variant patients. Neurological abnormalities were more frequent in the patients with moderate XP (n = 17, 64.5%) than with severe XP (p = 0.051).

Conclusion

This difference in a group of Tunisian patients confirms the heterogeneous nature of XP and is probably due to genetic heterogeneity.     

Impaired ability to shift weight onto the non-paretic leg in right-cortical brain-damaged patients

Background

: Stroke patients experience postural instability that can impede functional improvements in their gait. However, the precise functions of the dominant and non-dominant hemispheres in controlling static standing posture and weight-bearing remain unclear.

Objective

: To investigate differences in balancing ability between right-handed patients with right and left hemispheric lesions.

Methods

: Weight shifting was quantitatively evaluated to determine the ability of patients to control their balance in a static posture and during conscious weight shifting onto the paretic or non-paretic leg. Participants were enrolled from a consecutive series of stroke patients attending a rehabilitation program (n = 49; 31 male, 18 female; mean age 69.3 ± 9.4 years). Age-matched normal controls were recruited as volunteers (n = 12; 4 male, 8 female; mean age 67.9 ± 4.9 years).

Results

: Patients with cortical lesions in the right hemisphere were able to shift less weight onto the non-paretic leg than patients with cortical lesions in the left hemisphere (p < 0.05). There were no correlations between the existence of unilateral spatial neglect and the percentage of weight shifted onto the non-paretic leg, static standing posture (r = 0.27, p = 0.40) or dynamic standing posture (r = −0.37, p = 0.24). In contrast, there was a significant correlation between the percentage of weight consciously shifted onto the non-paretic leg and the existence of anosognosia (r = 0.74, p = 0.006), but not between static standing posture and anosognosia (r = −0.15, p = 0.63).

Conclusion

: Patients with right cortical hemispheric lesions were able to shift less body weight onto their non-paretic leg. These patients should be encouraged to practice shifting their weight towards their non-paretic leg to improve their balance.     

Perceived burden of illness in patients entering for treatment in a university hospital - is the threshold to secondary care higher for patients with depression than for those with somatic disorders?

Background

The threshold to secondary health care should be similar for all patients independent of the underlying disease. This study compared, using a validated health-related quality of life (HRQoL)-instrument, whether the perceived burden of illness is similar in patients admitted for secondary care treatment into a university hospital because of one of six common conditions.

Methods

HRQoL, assessed by the generic 15D instrument before elective treatment, was compared in six groups: operative treatment of cataract (n = 219), operative treatment of cervical or lumbar radicular pain (n = 270), hysterectomy due to benign uterine conditions (n = 337), hip or knee replacement surgery (n = 223), coronary angiography due to suspected coronary artery disease (n = 261), and secondary care treatment of depression (n = 89).

Results

Mean (±SD) HRQoL score was clearly highest in patients with benign uterine conditions (0.908 ± 0.071) and lowest in patients with depression (0.729 ± 0.120) (P < 0.001 between the groups). Also all the other groups had a significantly (P < 0.001) higher baseline HRQoL score (ranging from 0.802 to 0.824) than patients with depression. Outcome of treatment, in terms of HRQoL improvement, was in depressive patients at least equal, and in some cases even better, than that in the other groups.

Discussion

Our results imply that, at least concerning perceived burden of illness, patients with depression are worse off when admitted to secondary care treatment than patients with many somatic conditions. That may be a consequence of poor motivation of depressive patients to seek treatment or that, contradictory to guidelines, the health care system does nor give priority to those worst off and sets a higher threshold for specialized care of patients with depression than of those with common somatic disorders.     

Significance of minor traumatic lesions in focal head injuries

We investigated the significance of minor traumatic lesions associated with focal head injuries. Patients included in the study were admitted between January 2003 and December 2007 and had sustained a head injury with focal injury and undergone MRI examination including T2^∗-weighted imaging. Patients were divided into two groups: (i) a T2^∗-positive group - those who had hypointense lesions at sites other than the original injury site as shown by T2^∗-weighted MRI (n = 12); and (ii) a control group without hypointense lesions at sites other than the original injury (n = 25). The median Glasgow Outcome Scale score was significantly lower in the T2^∗-positive group (median = 4; range = 4-5) than in the control group (median = 5; range = 4-5; p = 0.003). We conclude that patients with a focal head injury and minor traumatic lesions are likely to have a poorer prognosis than patients without additional minor traumatic lesions.     

Excessively elevated C-reactive protein after surgery for temporal lobe epilepsy

Objective

We present a series of 87 patients who underwent anteromesial temporal lobe resections for therapy refractory temporal lobe epilepsy. In addition to seizure outcome, we observed excessively elevated CRP-levels in this patient population.

Methods

We followed 87 patients (m = 39, f = 48; mean age 33.73 ± 12.92, range 5–67 years) who underwent surgery between July 2003 and November 2011. Seizure outcome was classified in all patients according to the ILAE-classification by Wieser et al. (mean follow-up: 38.72 months). CRP levels were measured in 59 patients of the epilepsy surgery group and in a control group of 44 consecutive patients with supratentorial tumors (22 glioblastomas, 22 meningiomas).

Results

Clinical benefit was seen in 96.6% of the patients (ILAE classes 1–4), 80.5% were completely seizure free (ILAE class 1). Post-OP CRP values were significantly higher in the epilepsy group (n = 59; mean CRP peak value: 100.86 mg/l, range: 16–258 mg/l) compared to the control group (n = 44; mean CRP peak value: 36.85 mg/l, range: 0.4–233 mg/l) (p < 0.001), but the correlation of mean CRP value and mean temperature peak is weak (r = 0.31).

Conclusions

Seizure outcome after surgery for temporal lobe epilepsy was excellent, CRP levels were excessively elevated in these patients in the absence of clinical infection and significantly higher compared to resections of supratentorial lesions.