During the 2002-2004 smallpox vaccination campaign, reported neurologic events were generally mild and self-limited, and no neurologic syndrome was identified at a rate above baseline estimates. Serious neurologic adverse events, such as postvaccinal encephalitis, Bell palsy, and Guillain-Barré syndrome, occurred in accordance with expected ranges.

An open-label extension study of the phase III trial of intramuscular interferon beta-1a (IFNbeta-1a-Avonex) was conducted to evaluate the immunogenicity and safety of IFNbeta-1a-Avonex over six years in patients with relapsing multiple sclerosis (MS). Patients who participated in the pivotal phase III study were offered enrolment; entry was also open to patients who had not participated. All patients received IFNbeta-1a-Avonex 30 microg intramuscularly once weekly for six years, for a treatment duration of up to eight years in patients who received IFNbeta-1a-Avonex in the phase III trial. Serum levels of IFNbeta antibodies were measured every six months using a screening enzyme-linked immunosorbent assay (ELISA) followed by an antiviral cytopathic effect assay to detect neutralizing antibodies (NAbs) in serum samples positive on ELISA. The incidence of adverse events and laboratory test results assessed safety. Of 382 total patients, 218 had participated in the phase III study (103 placebo, 115 IFNbeta-1a-Avonex) and 164 had not participated; 24 of the 164 were IFNbeta-naïve. At baseline, 281 patients were negative for IFNbeta antibodies (NAb-). NAbs (titre> or = 20) developed at any time over six years in 5% of these patients. Of 140 patients who had been on IFNbeta-1b-Betaseron, 49 were positive for NAbs (NAb+) at baseline; 11 of 115 who had been on IFNbeta-1a-Avonex were NAb+ at baseline. Thirty-nine of 49 patients who had been on Betaseron and were NAb+ had titres < 100; 36 of these 39 seroconverted to NAb- while on IFNbeta-1a-Avonex, with a median time of approximately six months. Ten patients who had been on Betaseron had NAb titres > or = 100; five remained NAb+ during six years on IFNbeta-1a-Avonex and five seroconverted to NAb-, but only after at least two years. Five patients who had been on IFNbeta-1a-Avonex during the clinical trial were NAb+ with titres < 100 at baseline; four seroconverted to NAb-, with a median time of two to three years. Six patients who had been on IFNbeta-1a-Avonex had NAb titres > or = 100; five of these remained NAb+ at six years. No patient with a NAb titre > 1000 seroconverted to NAb-, whether initially treated with IFNbeta-1a-Avonex or -Betaseron. Adverse events were similar to those observed in the pivotal phase III trial. Results from this trial indicated that IFNbeta-1a-Avonex was associated with a low incidence of NAbs and was well tolerated for up to eight years. Further, the results indicate that persistence of NAbs is dependent on titre and IFNbeta product.

Postoperative complications and nutritional deficits resulting from bariatric surgery can lead to severe vitamin-deficiency states, such as Wernicke's encephalopathy (WE). Patients with acute WE generally present with the classic clinical triad of inattentiveness, ataxia, and ophthalmoplegia. We describe a patient who presented with acute WE at 2 months after laparoscopic bariatric surgery. Initial MRI of the brain demonstrated the characteristic injuries of WE, and repeat imaging showed resolution after 4 months of thiamine supplementation, at which time the patient had normal gait but persistent memory deficits. Even with early recognition and aggressive therapy, acute WE commonly results in permanent disability due to the irreversible cytotoxic effects on specific regions of the brain. Since the clinical onset of acute WE follows a predictable time-course in post-bariatric surgery patients with malnutrition, we recommend prevention by administration of parenteral thiamine beginning at 6 weeks postoperatively in malnourished patients.

Carotid endarterectomy is rapidly becoming one of the most commonly performed major surgical operations in the United States, in part because of the greater availability of noninvasive techniques to accurately diagnose extracranial carotid arterial disease and a low reported morbidity and mortality. We retrospectively reviewed the records for all carotid endarterectomies performed in the greater Cincinnati area for a recent 12-month period and examined the impact of surgical specialty and operative caseload on the results. Altogether, 750 operations were Performed on 656 patients by 61 surgeons working in 16 general medical,surgical hospitals. Overall, strokes occurred in 5.1% of all patients; 2.3% of patients died. Symptomatic patients had a significantly higher risk of suffering a postoperative stroke compared with asymptomatic patients (6.5% vs. 3.7%), although the risk of death was virtually identical (2.4% vs. 2.1%). When the operating surgeons were classified into four types on the basis of their previous training, no statistically significant differences in either postoperative stroke or death could be identified. Furthermore, when the surgical caseloads of these physicians were grouped into three categories (i.e., less than 12 each year, more than 50 each year, and a group between these two extremes), no significant differences in outcome were seen. We concluded that our community-wide results for carotid endarterectomy were not comparable to those previously published from specialized centers and that these results did not appear to be influenced by the type of formal surgical specialty or operative caseload.

Changes in the practice of carotid endarterectomy were studied by review of all endarterectomies performed in the greater Cincinnati area during 1980 and from July 1983 through June 1984. The number of operations rose from 431 to 750 (74% increase). The perioperative stroke rate fell from 8.6% in 1980 to 5.1% in 1983-1984; operative mortality declined from 2.8% to 2.3%; and the combined stroke or death rate declined from 9.5% to 6.5%. Asymptomatic carotid artery disease was the indication for 50% of the endarterectomies during both time periods. The combined stroke or death rate for asymptomatic patients declined from 6.9% to 5.3%, but both rates were higher than the 3% suggested as acceptable for prophylactic carotid endarterectomy. We conclude that carotid endarterectomy is becoming an increasingly common procedure, that morbidity continues to decline, and that mortality continues to be significant. Citywide surgical morbidity and mortality remain excessive for patients with asymptomatic carotid disease.

No abstract

Carbamazepine is a well-established, effective treatment of complex partial seizures and is well tolerated in most patients. The adverse effects of carbamazepine include aplastic anemia, agranulocytosis, pancytopenia, bone marrow depression, thrombocytopenia, cardiac conduction abnormalities, congestive heart failure, and peripheral edema. Hypertension or hypotension has also rarely been documented in patients with either therapeutic or toxic blood levels of carbamazepine. It is possible that carbamazepine-induced hypertension in those with therapeutic blood levels is rarely seen because most of the patients who begin treatment are young and do not have baseline hypertension. The authors describe a patient of African-American descent with a history of controlled essential hypertension who developed severe uncontrolled hypertension when started on carbamazepine. Treatment with additional antihypertensive medications did not reduce his blood pressure. In addition, he developed two episodes of transient neurologic deficits, the symptoms of which consisted of dysarthria, vertigo, and unstable gait. A substantial reduction of his carbamazepine dose resulted in the control of his blood pressure and no recurrence of his symptoms.

Idiopathic intracranial hypertension and low cerebrospinal pressure are 2 conditions that are thought to be on opposite ends of the cerebrospinal pressure spectrum. Headache is the prominent component of both conditions. We describe a patient whose evaluation for idiopathic intracranial hypertension resulted in a postlumbar puncture headache. Although not entirely intuitive, we suggest that the 2 conditions can be present in the same patient.