A rare cause of young-onset dementia

A 39-year-old woman developed progressive cognitive impairment with neuropsychiatric features, bruxism and seizures; she had a background of recurrent bony fractures. The case formed the clinicopathological conference at the Association of British Neurologists Annual meeting 2022.

Experiences of remote consulting for patients and neurologists during the COVID-19 pandemic in Scotland

BACKGROUND

Remote consulting is an emerging model in managing chronic neurological conditions and has been widely implemented during the COVID-19 pandemic. The objective of this national survey was to investigate the initial experiences of remote consulting for neurologists and patients with established neurological conditions under follow-up during the first COVID-19 phase.

METHODS

In collaboration with the Scottish Association of Neurological Sciences and the Neurological Alliance of Scotland, we conducted a web-based survey of neurologists and patients between October and November 2020.

FINDINGS

Data was available for 62 neurologists and 201 patients. The consensus among neurologists was that remote consulting is a satisfactory way of delivering healthcare in selected groups of patients. For practical and technical reasons, there was preference for phone over video consultations (phone 63% vs video 33%, p=0.003). The prevailing opinion among clinicians was that considerable training interventions for remote consultation skills are required ('yes' 63% vs 'no' 37%, p=0.009) to improve clinician consultation skills and successfully embed this new model of care.Most patients perceived remote consultations as safe, effective and convenient, with 89% of patients being satisfied with their remote consultation experience. Although traditional face-to-face consultations were the favoured way of interaction for 62% of patients, a significant proportion preferred that some of their future consultations be remote.

INTERPRETATION

Although not a replacement for face-to-face consultations, this survey illustrates that remote consulting can be an acceptable adjunct to traditional face-to-face consultations for doctors and patients. More research is required to identify overall safety and applicability.

Visual loss with chronic meningeal and systemic inflammation

A 46-year-old man presented with worsening vision in the context of long-standing optic disc changes, bilateral sensorineural hearing loss, chronic aseptic meningitis, rash, arthralgia and raised inflammatory markers. The differential diagnoses of neoplasia, infection and inflammation are discussed. We highlight a condition that can present to adult neurologists, with successful diagnosis leading to targeted treatments that transform patient outcomes. This case was presented at the Association of British Neurologists Annual Meeting 2020 as a Clinicopathological Conference (CPC).

Clinicopathological case: headache and systemic inflammatory illness—Occam vs Hickam

A 63-year-old woman presented with a sudden headache, which persisted and subsequently changed in character. Over time, constitutional features developed, leading to an unexpected diagnosis. This report documents the clinicopathological conference at the Association of British Neurologists Annual Meeting 2019.

Enhanced estrogen removal in activated sludge processes through the optimization of the hydraulic flow pattern

The removal of β-estradiol (E2) and α-ethinylestradiol (EE2) in biological wastewater treatment plants (WWTP) would need to be improved in order to comply with prospective Environmental Quality Standards (EQS) of 0.4 and 0.035 ng.L^-1 respectively. The effluent concentration of a micropollutant in an activated sludge process is a function of the removal rate, the hydraulic retention time (HRT) and the flow pattern, which is usually overlooked. In order to better understand this aspect, we carried out tracer studies in eight WWTPs in the UK and found that relatively modest changes in aeration tanks would translate into tangible improvements in their flow pattern. We further evaluated the degradation rates for E1 (estrone), E2, E3 (estriol) and EE2 in each WWTP and we estimated that the modification of the flow pattern would be sufficient to place effluent concentrations of E2 (23.2 L∙g_VSS^-1∙d^-1<k_bio<210 L∙g_VSS^-1∙d^-1) far below the prospective EQS, while EE2 (0.3 L∙g_VSS^-1∙d^-1<k_bio<2.9 L∙g_VSS^-1∙d^-1) would have to rely on river dilution for compliance. Regarding E1 and E3, with no prospective legislation, the modifications would place E3 (9.9 L∙g_VSS^-1∙d^-1<k_bio<39.5 L∙g_VSS^-1∙d^-1) effluent concentrations easily below its predicted no-effect concentrations (PNEC = 60 ng.L^-1) while for E1, (2.6 L∙g_VSS^-1∙d^-1<k_bio<19.2 L∙g_VSS^-1∙d^-1) it would very much depend on the degradation rates of the specific WWTP (PNEC = 6 ng.L^-1). Improvement in flow pattern had the additional benefit of improving the effectiveness of other plausible changes in HRT or biological removal rates. Managing the flow pattern of existing WWTPs is a cost-efficient tool for managing the fate of estrogens.

Clinicopathological case: progressive somnolence and dementia in an accountant: when the shine rubs off the gold standard

A 63-year-old accountant developed progressive somnolence, cognitive decline, gait disturbance and cerebellar dysfunction with autonomic features. This report documents the clinicopathological conference at the 39th Edinburgh Advanced Neurology Course 2017.

Coupled virus - bacteria interactions and ecosystem function in an engineered microbial system

Viruses are thought to control bacterial abundance, affect community composition and influence ecosystem function in natural environments. Yet their dynamics have seldom been studied in engineered systems, or indeed in any system, for long periods of time. We measured virus abundance in a full-scale activated sludge plant every week for two years. Total bacteria and ammonia oxidising bacteria (AOB) abundances, bacterial community profiles, and a suite of environmental and operational parameters were also monitored. Mixed liquor virus abundance fluctuated over an order of magnitude (3.18 × 10⁸-3.41 × 10⁹ virus's mL^-1) and that variation was statistically significantly associated with total bacterial and AOB abundance, community composition, and effluent concentrations of COD and NH₄⁺- N and thus system function. This suggests viruses play a far more important role in the dynamics of activated sludge systems than previously realised and could be one of the key factors controlling bacterial abundance, community structure and functional stability and may cause reactors to fail. These findings are based on statistical associations, not mechanistic models. Nevertheless, viral associations with abiotic factors, such as pH, make physical sense, giving credence to these findings and highlighting the role that physical factors play in virus ecology. Further work is needed to identify and quantify specific bacteriophage and their hosts to enable us to develop mechanistic models of the ecology of viruses in wastewater treatment systems. However, since we have shown that viruses can be related to effluent quality and virus quantification is simple and cheap, practitioners would probably benefit from quantifying viruses now.

How to do it: investigate exertional rhabdomyolysis (or not)

Rhabdomyolysis is the combination of symptoms (myalgia, weakness and muscle swelling) and a substantial rise in serum creatine kinase (CK) >50 000 IU/L; there are many causes, but here we specifically address exertional rhabdomyolysis. The consequences of this condition can be severe, including acute kidney injury and requirement for higher level care with organ support. Most patients have ‘physiological’ exertional rhabdomyolysis with no underlying disease; they do not need investigation and should be advised to return to normal activities in a graded fashion. Rarely, exertional rhabdomyolysis may be the initial presentation of underlying muscle disease, and we review how to identify this much smaller group of patients, who do require investigation.

Flow cytometric quantification of viruses in activated sludge

Viruses may play a critical role in the microbial dynamics of activated sludge systems; however the difficulty of their quantification makes long term and large scale studies costly, timely and challenging. Thus a flow cytometric protocol was optimised and employed to determine virus abundance in activated sludge samples. The best flow cytometry signature and highest virus count was obtained by separating the indigenous floc-associated viruses using Tween 80 and sodium pyrophosphate, diluting the sample with Tris-EDTA and staining with SYBR Green II. Using the optimised protocol viral concentrations from 25 activated sludge plants were determined, with average concentrations of 2.35 × 10⁹ mL⁻¹ observed. Direct counts by transmission electron microscopy were highly correlated with flow cytometric counts (p = <0.05 and r² = 0.77), with concentrations from both quantification methods comparable at the order of magnitude level. The high counting efficiency, ease of preparation and rapidity and reproducibility of analysis makes flow cytometric quantification of viruses in activated sludge ideal for routine investigation and thus invaluable in unravelling the complexity of phage host interactions in such systems.

National survey of UK medical students on the perception of neurology

BACKGROUND

Medical students perceive neurology to be a difficult subject, a phenomenon described as "neurophobia". Studies investigating student attitudes towards neurology have so far been limited by small sample sizes as a consequence of being conducted within a single medical school or region. We aimed to conduct the first national survey of the perception of neurology among UK medical students.

METHODS

A 24 question online survey was designed and distributed in the form of a web-link to all UK medical schools. Responses were collected for 10 weeks with reminders sent at 3 and 6 weeks. A prize-draw of £300 was offered upon completion of the survey.

RESULTS

2877 medical students from 25 of 31 medical schools responded. Students found neurology to be significantly more difficult than other specialties and were least comfortable drawing up a neurological differential diagnosis compared to other specialties (p < 0.0001 for neurology vs. each of the other specialties). Neuroanatomy was regarded as the most important factor contributing to neurology being perceived as difficult.

CONCLUSIONS

The findings of the first national survey addressing this issue are consistent with previous research. The perception of neurology remains unchanged, in contrast to the rapidly changing demands of neurological care in an ageing population. Neurological examination and formulating a differential diagnosis are important skills in any medical specialty, and combatting "neurophobia" in medical students is therefore essential.

Delayed diagnosis of oculopharyngeal muscular dystrophy in Scotland

INTRODUCTION

Oculopharyngeal muscular dystrophy (OPMD) presents with progressive ptosis, dysphagia and limb girdle weakness, and is caused by expansion of a trinucleotide tandem repeat within the gene encoding poly-(A) binding protein 2.

AIM

To review the clinical manifestations of all genetically confirmed patients with OPMD in Scotland identified since 2002, and to estimate the delay between symptom onset and diagnosis. Method Retrospective case note review.

RESULTS

The authors identified 17 patients. The commonest first symptom was ptosis at about the age of 60 years. Three to 20 years elapsed from the onset of ptosis to OPMD diagnosis. In 14 (82%) patients, dysphagia had developed by the time of diagnosis, and four (24%) out of these 14 patients with dysphagia had undergone a decade of investigation and treatment for pharyngeal problems. Thirteen patients (77%) also had symptoms of limb girdle muscle weakness. Every patient had a first-degree relative with ptosis.

CONCLUSIONS

OPMD could have been diagnosed earlier in every patient in this case series. Greater awareness of OPMD among ophthalmologists, gastroenterologists and otolaryngologists may lead to earlier diagnosis, improved management and avoidance of unnecessary investigations.

Screening patients with a family history of subarachnoid haemorrhage for intracranial aneurysms: screening uptake, patient characteristics and outcome

BACKGROUND AND PURPOSE

People with one or more first degree relative affected (FDRA) by aneurysmal subarachnoid haemorrhage (aSAH) are at a higher lifetime risk of an aSAH than those without a family history. Screening may be worthwhile for people with two or more FDRA by aSAH. Little is known about the characteristics of people with a family history of aSAH who undergo screening in clinical practice.

METHODS

Observational analysis of consecutive attendances at an intracranial aneurysm screening clinic.

RESULTS

Of 96 adults seen, 19 did not have a family history of aSAH and 77 had one or more FDRA by aSAH: 35 had two or more FDRA, 21 had one FDRA plus one or more affected second degree relative and 21 had one FDRA only. In these three respective groups, 29 (83%), 15 (71%) and five (24%) adults underwent screening, of whom six (21%), two (13%) and one (20%) had an aneurysm detected (p=0.5). Of the nine patients with aneurysms, four underwent treatment. Considering other risk factors, adults with two or more FDRA were more likely to be hypertensive (OR 3.3, 95% CI 1.0 to 10.8; p=0.046) but were no more likely to smoke or drink to excess than adults with one FDRA. Adults who underwent screening were more likely to be hypertensive and drink alcohol to excess (both p=0.03), but were no more likely to smoke than those who were not screened.

CONCLUSIONS

In clinical practice, people undergoing intracranial aneurysm screening had stronger family histories of aSAH and they were also more likely to have modifiable risk factors for aSAH.

Autoimmune limbic encephalitis

Autoimmune limbic encephalitis is an increasingly recognised cause of cognitive decline and confusion. The typical presentation is with subacute cognitive decline, behavioural disturbance and seizures. Magnetic resonance imaging may show characteristic changes in the medial temporal regions. The diagnosis is confirmed by identification of elevated voltage-gated potassium channel antibody (VGKC-Ab) titres. It is a highly treatable condition, often responding well to intravenous immunoglobulin or steroids. Recognition of autoimmune limbic encephalitis is sometimes delayed--usually because the diagnosis has not been considered--which can result in long-term neurological consequences.

A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study

OBJECTIVE

To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bell's palsy, improves the chances of recovery at 3 and 9 months.

DESIGN

A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification.

SETTING

Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites.

PARTICIPANTS

Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset.

INTERVENTIONS

Patients were randomised to receive active preparations or placebo for 10 days: (1) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo.

OUTCOME MEASURES

The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness.

RESULTS

Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p < 0.001). The number needed to treat (NNT) in order to achieve one additional complete recovery was 6 (95% CI: 4 to 9). There was no significant difference between the aciclovir comparison groups (71.2% for aciclovir and 75.7% for no aciclovir). Nine-month assessments of patients recovered were 94.4% for prednisolone compared with 81.6% for no prednisolone, a difference of + 12.8% (95% CI: + 7.2% to + 18.4%, p < 0.001); the NNT was 8 (95% CI: 6 to 14). Proportions recovered at 9 months were 85.4% for aciclovir and 90.8% for no aciclovir, a difference of -5.3%. There was no significant prednisolone-aciclovir interaction at 3 months or at 9 months. Outcome differences by individual treatment (the four-arm model) showed significant differences. At 3 months the recovery rate was 86.3% in the prednisolone treatment group, 79.7% in the aciclovir-prednisolone group, 64.7% in the placebo group and 62.5% in the aciclovir group. At 9 months the recovery rates were respectively 96.1%, 92.7%, 85.3% and 78.1%. The increase in recovery rate conferred by the addition of prednisolone (both for prednisolone over placebo and for aciclovir-prednisolone over aciclovir) is highly statistically significant (p < 0.001). There were no significant differences in secondary measures apart from Health Utilities Index Mark 3 (HUI3) at 9 months in those treated with prednisolone.

CONCLUSIONS

This study provided robust evidence to support the early use of oral prednisolone in Bell's palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

Nitrification-denitrification in waste stabilisation ponds: a mechanism for permanent nitrogen removal in maturation ponds

A pilot-scale primary maturation pond was spiked with (15)N-labelled ammonia ((15)NH(4)Cl) and (15)N-labelled nitrite (Na(15)NO(2)), in order to improve current understanding of the dynamics of inorganic nitrogen transformations and removal in WSP systems. Stable isotope analysis of delta(15)N showed that nitrification could be considered as an intermediate step in WSP, which is masked by simultaneous denitrification, under conditions of low algal activity. Molecular microbiology analysis showed that denitrification can be considered a feasible mechanism for permanent nitrogen removal in WSP, which may be supported either by ammonia-oxidising bacteria (AOB) or by methanotrophs, in addition to nitrite-oxidising bacteria (NOB). However, the relative supremacy of the denitrification process over other nitrogen removal mechanisms (e.g., biological uptake) depends upon phytoplanktonic activity.

Blocking alpha4-integrins - A small molecule approach to treatment of multiple sclerosis

Inhibition of leukocyte trafficking using antibody blockade of the alpha4 (alpha4)-integrins has now been validated as a therapeutic approach for the treatment of multiple sclerosis (MS). This positive validation has led to the discovery of small molecule alpha4 antagonists that are progressing through clinical trials. The challenges in development of these antagonists will be discussed along with a clinical update on the most advanced candidates.

A universal threshold concept for hydrophobic mycolata in activated sludge foaming

Recent studies using quantitative fluorescence in situ hybridization (FISH) have supported the principle that there are mycolata concentration thresholds, above which foaming is likely to occur. In this study, we surveyed 14 wastewater treatment plants (WWTPs) in the UK, using quantitative FISH, to establish that the principle of a mycolata threshold (2 x 10(6) mycolata cells ml(-1) mixed liquor suspended solids) is an empirical though widely held value. In addition, we designed, optimized and applied probes for members of the less hydrophobic mycolata genera Corynebacterium and Dietzia, to show that these organisms dominated the mycolata populations in two non-foaming WWTPs where the mycolata concentrations were above the threshold value. We propose that the mycolata threshold value is only applicable to hydrophobic members of the mycolata.

Presence and activity of ammonia-oxidising bacteria detected amongst the overall bacterial diversity along a physico-chemical gradient of a nitrifying wastewater treatment plant

We wished to discover if we could gain greater insights into how biological treatment plants function by contrasting the presence and activity of the most abundant Bacteria in plug flow and completely mixed activated sludge plants. Presence was assessed by amplifying 16S rRNA gene fragments (using PCR) and activity by amplifying native 16S rRNA, using reverse-transcriptase PCR (RT-PCR), using Bacteria-specific primers. The amplified sequences were compared using denaturing gradient gel electrophoresis (DGGE). The plug flow plant exhibited a strong physico-chemical gradient with an initial anoxic zone, whilst the two completely mixed reactors did not. Similarities were observed between the profile of the banding pattern for presence and activity. However, in the plug flow reactor one prominent band was detected in the active population (16S rRNA) but was absent from the corresponding profile of the 16S rRNA gene. Sequencing of this band revealed its identity as a Nitrosomonas-like sequence. The intensity of the 16S rRNA sequenced varied along the physico-chemical gradient of the plug-flow reactor in a manner that coincided with the growth of ammonia-oxidising bacteria (AOB) and the loss of ammonia. This band was also absent from the completely mixed reactors, although significant numbers of AOB were detected in all systems ( approximately 10(6)-10(8)cells ml(-1)) by fluorescence in situ hybridisation (FISH). An abundant and highly active AOB population was present in the anoxic zone of the plug-flow reactor where up to 60% of the total ammonia was removed. An examination of nitrogen removal/production rates, together with the above data, reveal that complex nitrogen removal processes occur in this system. These data also enabled the calculation of a specific in situ growth rate for the AOB as 0.12h(-1).

Investigating glutamate receptor-like gene co-expression in Arabidopsis thaliana

There is increasing evidence of the important roles of glutamate receptors (GLRs) in plant development and in adaptation to stresses. However, the studies of these putative ion channels, both in planta and in Xenopus oocytes, may have been limited by our lack of knowledge of possible GLR heteromer formation in plants. We have developed a modification of the single-cell sampling technique to investigate GLR co-expression, and thus potential heteromer formation, in single cells of Arabidopsis thaliana leaves. Micro-EXpression amplification (MEX) has allowed us to amplify gene transcripts from a single cell, enabling expression of up to 100 gene transcripts to be assayed. We measured, on average, the transcripts of five to six different AtGLRs in a single cell. However, no consistent patterns of co-expression or cell-type-specific expression were detected, except that cells sampled from the same plant showed similar expression profiles. The only discernible feature was the detection of AtGLR3.7 in every cell examined, an observation supported by GUS staining patterns in plants stably expressing promoter::uidA fusions. In addition, we found AtGLR3.7 expression in oocytes induces a Ba2+-, Ca2+- and Na+-permeable plasma membrane conductance.

Early treatment with prednisolone or acyclovir in Bell's palsy

BACKGROUND

Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell's palsy), but their effectiveness is uncertain.

METHODS

We conducted a double-blind, placebo-controlled, randomized, factorial trial involving patients with Bell's palsy who were recruited within 72 hours after the onset of symptoms. Patients were randomly assigned to receive 10 days of treatment with prednisolone, acyclovir, both agents, or placebo. The primary outcome was recovery of facial function, as rated on the House-Brackmann scale. Secondary outcomes included quality of life, appearance, and pain.

RESULTS

Final outcomes were assessed for 496 of 551 patients who underwent randomization. At 3 months, the proportions of patients who had recovered facial function were 83.0% in the prednisolone group as compared with 63.6% among patients who did not receive prednisolone (P<0.001) and 71.2% in the acyclovir group as compared with 75.7% among patients who did not receive acyclovir (adjusted P=0.50). After 9 months, these proportions were 94.4% for prednisolone and 81.6% for no prednisolone (P<0.001) and 85.4% for acyclovir and 90.8% for no acyclovir (adjusted P=0.10). For patients treated with both drugs, the proportions were 79.7% at 3 months (P<0.001) and 92.7% at 9 months (P<0.001). There were no clinically significant differences between the treatment groups in secondary outcomes. There were no serious adverse events in any group.

CONCLUSIONS

In patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone. (Current Controlled Trials number, ISRCTN71548196 [controlled-trials.com].).

Alpha4-integrin antagonism — an effective approach for the treatment of inflammatory diseases?

Inhibition of leucocyte trafficking by antagonism of the alpha4 (alpha4)-integrin has now been validated as a therapeutic approach for the treatment of inflammatory diseases such as multiple sclerosis (MS) and inflammatory bowel disease (IBD). This validation has been overshadowed by three incidences of progressive multifocal leucoencaphalopathy (PML) in patients receiving natalizumab (Tysabri), a therapeutic monoclonal IgG antibody directed against alpha4-integrins. This led to the initial removal of natalizumab from the market. Following a safety review, it was reintroduced for the treatment of relapsing-remitting MS patients (with restrictions). This has led to a refocus on alpha4-integrins as a therapeutic target across the pharmaceutical industry. Recent advances in small molecule development are worth reviewing. New understanding of pharmacokinetics and selectivity will potentially contribute to the development of alpha4 antagonist with greater clinical efficacy and safety.

Synthesis and SAR of aminopyrimidines as novel c-Jun N-terminal kinase (JNK) inhibitors

The development of a series of novel aminopyrimidines as inhibitors of c-Jun N-terminal kinases is described. The synthesis, in vitro inhibitory values for JNK1, JNK2 and CDK2, and the in vitro inhibitory value for a c-Jun cellular assay are discussed.

Novel nucleotide triphosphates as potent P2Y2 agonists with enhanced stability over UTP

The synthesis of a series of novel C-linked nucleotide triphosphates is reported. These exhibit excellent agonist potency and selectivity for the P2Y2 receptor with a number of examples having EC50 values below 10 nM. Representative compounds from the N-linked and C-linked series showed enhanced metabolic stability compared with that of the natural ligand UTP.

Novel nucleotide triphosphates as potent P2Y2 agonists

The synthesis and P2Y2 activities of a novel series of nucleoside triphosphates are described. Many of these compounds were potent agonists of the P2Y2 receptor.

Epidemiology, clinical characteristics, and management of adults referred to a teaching hospital first seizure clinic

BACKGROUND

There are scarce data describing the epidemiology, clinical characteristics, and management of adults who suffer a suspected first seizure.

AIM

To describe the epidemiology, clinical characteristics, and management of adults with a suspected first seizure who are referred to a teaching hospital first seizure clinic over a one year period.

DESIGN

Prospective descriptive study.

METHODS

Data were collected on consecutive adults referred to the Royal Infirmary of Edinburgh between 4 February 2003 and 10 February 2004.

RESULTS

232 patients were referred to the first seizure clinic. Median age was 32 years; 53% of patients were male. Lower socioeconomic groups were more likely to present with a suspected first seizure. Nineteen per cent of patients were admitted to hospital after their suspected seizure episode. Appropriate driving advice was reported in 64% of cases. Seventy two per cent of patients were offered a first seizure clinic appointment within six weeks of referral. Nine per cent of patients had a subsequent seizure while awaiting review. Fifty two per cent of patients were confirmed as having a first seizure at the clinic, of which 56% were provoked by alcohol, recreational drugs, or sleep deprivation. Electroencephalography and computed tomography of the brain were the most common investigations ordered at the first seizure clinic (22% and 22% of patients respectively).

CONCLUSION

Adults who suffer a suspected first seizure, and who make a full neurological recovery, can be safely managed as an outpatient. Around half of these patients will have a specialist diagnosis of first seizure and alcohol will be a common precipitating factor.

Early management of adults with an uncomplicated first generalised seizure

A literature review of first seizures in adults was performed and a management algorithm was constructed. This review highlights the importance of a thorough history and examination, routine biochemistry and haematology, an electrocardiogram, selected neuroimaging, discharge planning with driving and lifestyle advice, and follow-up in a specialist clinic.

A novel series of potent and selective IKK2 inhibitors

A novel series of aminopyrimidine IKK2 inhibitors have been developed which show excellent in vitro inhibition of this enzyme and good selectivity over the IKK1 isoform. The relative potency and selectivity of these compounds has been rationalized using QSAR and structure-based modelling.

Survival from accidental strangulation from a scarf resulting in laryngeal rupture and carotid artery stenosis: the "Isadora Duncan syndrome". A case report and review of literature

In 1929 the dancer Isadora Duncan died from strangulation and carotid artery insult when her scarf caught in the wheels of a motor vehicle in which she was travelling. As part of the Edinburgh Festival scene, cycle propelled rickshaws are in popular use as short range taxis. The case is presented of a student who sustained a laryngeal rupture from strangulation with a scarf in the same way as Isadora. Despite an out of hospital cardiorespiratory arrest, severe laryngeal trauma, and carotid artery damage resulting in hemiparesis, the patient was successfully resuscitated and recovered with no neurological deficit. It is believed that this is the first recorded survival from this condition.

Microbial mechanisms of carbon removal in subsurface flow wetlands

The microbial mechanisms of carbon removal in subsurface flow wetlands were studied, in one wetland with plants and one without plants. Particular emphasis was given to the influence of plants in the treatment process. Wetlands without plants showed higher carbon removal than those with plants, 63% and 51%, respectively (p < 0.05). Molecular analysis of the bacterial diversity, growth rates and specific microbial activities showed that the two wetlands were different, especially towards the outlet of the two systems. Sulphate reducers and methanogens were found in both wetlands, and they are thought to be the main removers of soluble organic carbon in these two systems.

Synthesis and profile of SCH351591, a novel PDE4 inhibitor

The syntheses and pharmacological profiles of some 2-trifluoromethyl-8-methoxyquinoline-5-carboxamides are described. SCH351591 is a potent selective inhibitor of phosphodiesterase type 4 (PDE4).

7-Methoxyfuro[2,3-c]pyridine-4-carboxamides as PDE4 inhibitors: a potential treatment for asthma

The synthesis and pharmacological profile of a novel series of 7-methoxy-furo[2,3-c]pyridine-4-carboxamides is described. Some of these compounds were found to be potent inhibitors of phosphodiesterase type 4 (PDE4).