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A 35-year-old man presented with myalgia and bilateral hand weakness, 3 days after the onset of lethargy, fevers and rigours. The hand weakness caused functional impairment including difficulty pressing keys on his mobile phone. On examination, there was mild bilateral hand weakness with normal reflexes. His serum creatine kinase was mildly raised at 503 U/L (24-195), viral PCR throat swab was negative and electromyogram showed subtle myopathic changes in the distal forearm muscles. Nerve conduction studies found no evidence of neuropathy. Forced vital capacity was reduced on admission (1.5 L) but improved within 24 hours (2.3 L). We gave supportive intravenous fluids and his weakness improved within 48 hours. He was discharged and reported that the weakness had fully resolved within weeks. The diagnosis was viral myositis. Distal forearm myositis rarely follows H1N1 influenza in adults but is an important differential for postinfective neurological symptoms.

Brown–Vialetto–Van Laere (BVVL) is a rare neurodegenerative isorder caused by mutations in the human intestinal riboflavin ransporter genes, leading to riboflavin deficiency. It is characerised by bulbar palsy, respiratory insufficiency and sensorineural eafness. Some cases of BVVL have been successfully treated with iboflavin supplementation. Although BVVL is most commonly iagnosed in children it may also present in adults. We describe case of BVVL in a 27-year-old female.

Background High circulating platelet counts have been associated with poor prognosis in a variety of solid tumours such as breast, renal and lung cancer. We investigated the significance of a high pre-operative platelet count on overall survival in patients with stages I–IV colorectal cancer. Patients and methods 630 Consecutive patients who colorectal cancer resection between 2004 and 2007 with a full blood count taken 14 days prior to the surgery were assessed. Male:female 7:5, median (range) age 73 (40–99 years). Thrombocytosis was defined as platelet count of ≥450 × 10 9 /L. The relationship between platelet count, pathological features and overall survival was assessed. Results : Mantel–Cox regression showed that platelet count does not predict survival on multivariate analysis ( p = 0.067). Thrombocytosis was present in 51/627 (8.1%) of cases. There was no statistically significant difference in mean survival ( p = 0.067) observed in patients with platelet count 9 /L ( n = 576; 95%CI: 1550.5–1405.4 SE 37.0) versus ≥450 × 10 9 /L ( n = 51, CI: 1261.6–955.0, SE 78.2). There was also no correlation between Dukes stage and thrombocytosis. Conclusion(s) In our study, pre-operative thrombocytosis is not a prognostic indicator of survival in colorectal cancer patients regardless of pathological stage.

We report the observation of new isomerization effects in the UV-photodissociation of trans-crotonaldehyde upon multiphoton excitation by the third harmonic (355 nm) pulses of a Nd:YAG laser. A time-of-flight mass spectrometric analysis reveals formation of acetaldehyde, acetyl, and methoxy radical cations as signatures of isomerization processes. A small segment of the multiphoton ionization spectrum of jet-cooled crotonaldehyde is recorded by tuning the laser frequency around 355 nm. An oxetene type transient intermediate in the ground state has been considered for acetaldehyde formation following a photochemical model suggested earlier (Reguero ; et al. J. Am. Chem. Soc. 1994, 116, 2101-2114) for such compounds. Likewise, for methoxy radical formation, a trans-cis isomerization about the C═C double bond has been considered in a triplet surface. Electron ionization mass spectra of the compound are also recorded by varying the electron kinetic energy in the range 11-70 eV. Ionic fragments in the mass spectra of the two ionization processes are dramatically different. Our suggested mechanisms for isomerization and fragmentation channels are substantiated by density functional theory calculations. Combined experimental and calculated data lead us conclude that isomerization occurs in neutral potential energy surfaces prior to dissociation and photoionization.

An 80-year-old male patient presented with abdominal pain, paroxysmal diaphoresis, diarrhoea and vomiting. CT scan revealed a small bowel endocrine carcinoma (or 'carcinoid' tumour), but the absence of hepatic disease. The lesion was excised 'en-bloc'. Intra-operatively, there was wide fluctuation in blood pressure associated with tumour manipulation, with hyper- and hypotension. Carcinoid syndrome usually occurs from gastrointestinal tumours when hepatic metastases occur, causing flushing, diarrhoea, bronchoconstriction and murmurs from cardiac valvular lesions. This patient did not have radiological evidence of hepatic metastasis, but the syndrome could still occur with midgut tumours via local invasion of the retroperitoneal circulation, or by action of substances other than serotonin that do not undergo hepatic metabolism.

A 67-year-old woman abruptly developed acute pulmonary oedema, severe bradycardia and then cardiac arrest while in hospital 6 days after an elective hernia repair. She was resuscitated, intubated and transferred to the intensive care unit. Within 24 hours, she began to display repetitive, generalised myoclonic jerks that failed to respond to therapy with conventional anticonvulsants; an electroencephalogram confirmed myoclonic status. After administration of levetiracetam was begun on Day 3, myoclonic jerks reduced, and there was gradual clinical improvement. By Day 6 after the arrest, the patient was alert and oriented (Glasgow Coma Score, 15/15). Although she died on Day 11 after massive haemoptysis and cardiac arrest, this patient demonstrates the possibility of reasonable neurological recovery despite early onset of myoclonic status.

IntroductionPrimary Central Nervous System lymphoma (PCNSL) is responsible for 5% of all primary brain tumours within the UK. Barriers to diagnosis include steroid-responsiveness/false-negative biopsy and poor CSF sensitivity. We performed a pilot audit reflecting 5 years experience of PCNSL diagnosis based on criteria derived from 2011 British Neuro-Oncology guidelines.MethodsRetrospective case note and electronic patient record review for patients between 2008 to 2013 with biopsy-proven label of PCNSL. Imaging and staging results were reviewed to exclude secondary/metastatic disease.Results20 patients were identified; median age of 58 and 60% were male. Top three clinical presentations were cognitive, paresis and ataxia. Median duration of symptoms was 21 days (range 3 to 180) and median time to biopsy was 14 days.Pre-biopsy5 patients had negative CSF, 20% had steroids with documented clinical reason, 5% had record of HIV status checked and 88% had CT staging.ConclusionDespite limitations, this audit identified that the majority of these patients received steroids pre-biopsy, but in some cases, this may have reasonably been withheld. There is scope for a diagnostic algorithm to highlight safe withholding of steroids, early HIV testing and appropriate staging investigations, downplaying the importance of CSF sampling.

We present two cases of cerebral fat embolism. Both patients were 21-years old, male and involved in high impact road traffic collisions with no immediate neurological deficits.Patient A underwent intra-medullary nailing of right tibia/fibular fractures within 12 hours, and had external fixation for bilateral distal femoral fractures. Post-operatively, GCS was 6. Subsequent intracranial MR imaging showed widespread cerebral hypointense punctate foci on SWI (susceptibility-weighted imaging), some with associated restriction on DWI (diffusion-weighted imaging). Despite initial period of coma lasting weeks and inpatient admission over 5 months, he has been discharged to a neuro-rehabilitation unit and continues to show physical and cognitive improvement (MRS score of 3).Patient B underwent intra-medullary nailing for a femoral shaft fracture within 24 hours. Post-operatively, GCS was 9, he developed a petechial rash and became hypoxic. MR brain showed bilateral centrum semiovale DWI restriction, and again, widespread SWI punctate abnormalities. He was discharged within weeks and currently lives at home with his parents (MRS of 2).These cases show the spectrum of radiological abnormalities, the utility of SWI, and highlight that although neurological injury may be severe, there is potential for significant recovery.

PURPOSE. To investigate the relative contribution of visual and other factors to quality of life among elderly women with bilateral cataract. METHODS. Data were analyzed from a trial of first-eye cataract surgery. Visual parameters, general health, and social variables, and disease-specific (VF-14 Index of Visual Function), generic (Euroqol: EQ-5D, London Handicap Scale, Barthel), and intermediate (anxiety, depression, and activity) outcomes were measured at baseline and 6 months later, when approximately half the group had had surgery. RESULTS. Three hundred six participants provided data at baseline, and 289 at 6 months. At baseline, acuity, stereopsis, and contrast sensitivity were all associated with quality of life. Acuity and stereopsis were most strongly and consistently associated. Change in VF-14 was associated with changes in stereopsis and contrast sensitivity, while change in handicap was associated with change in stereopsis. CONCLUSIONS. Acuity, stereopsis, and contrast sensitivity each contributed to quality of life, across a range of measures, in elderly women with cataract. Acuity was marginally the most consistently and generally the most strongly associated, but in some analyses stereopsis was more important. Change in quality of life was associated with change in stereopsis and contrast sensitivity.