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Objectives: Positional obstructive sleep apnea (POSA) is common and affects sleep quality. This study was to identify the efficacy of using a Thai traditional triangle cushion as a position device for therapy in POSA. Methods: This open-label, self-control, prospective intervention study enrolled adult patients with POSA. The 8-weeks positional advice was performed, followed by 8-weeks using a Thai triangle cushion. Study outcomes were to measure changes in Epworth sleepiness scale (ESS) scores and 36-Item Short Form Health Survey (SF-36) and problems/complaints during the study. Results: There were 10 patients enrolled in total, with a mean age of 55.8 years old (SD 11.3), with an average apnea-hypopnea index (AHI) of 26.1, a supine AHI of 35.3, a non-supine AHI of 8.6 and the average baseline ESS was 10 (SD3.5). The positional advice did not improve the ESS score from baseline [the mean difference in ESS score of +0.20 (95%CI-2.01 to 2.41, p-value 0.84)]. Using cushion intervention significantly reduced the ESS score from baseline [-3.6 (95%CI-5.00 to-2.20), p-value

Several screening questionnaires for obstructive sleep apnea (OSA) have been introduced. No study has compared the performance of different questionnaire in the same patients with epilepsy. Herein, we compare the performance characteristics of four common questionnaires for assessing the probability of OSA in patients with epilepsy.This cross-sectional multicenter study was conducted among adult epilepsy patients attending neurology and general medical clinics in Thailand. Before performing full polysomnography (PSG), all participants completed the STOP-BANG, STOP-BAG, SA-SDQ, and NoSAS questionnaires. OSA was defined by apnea/ hypopnea index (AHI) criteria of AHI: ≥ 5, ≥ 15, and ≥ 30. Discriminatory ability was assessed by area under the receiver operating characteristics (ROC) curve (AUC) and likelihood ratio. To improve discriminative ability, we created 3 ranges of the score to predict lower, middle, and higher probability of OSA as defined by each diagnostic criterion.A total 166 patients with epilepsy were included. OSA prevalence was 38%. Overall, NoSAS had higher AUC at all AHI criteria but not significantly higher than that of other scales. Using prediction cut-points for NoSAS of ≥ 4 and ≥ 8 to predict OSA defined by AHI ≥ 5, the likelihood ratios for the 3 ranges were 0.37, 2.22 and 9.81 respectively.Among the 4 scales, the 2-cut-point NoSAS score had the highest discriminatory ability at each AHI cutoff.

OBJECTIVE Mechanisms underlying immune activation and HIV-associated neurocognitive disorders (HAND) in untreated chronic infection remain unclear. The objective of this study was to identify phenotypic and transcriptional changes in blood monocytes and CD4 T cells in HIV-1-infected and uninfected individuals and elucidate processes associated with neurocognitive impairment. DESIGN A group of chronically HIV-1-infected Thai individuals (n = 19) were selected for comparison with healthy donor controls (n = 10). Infected participants were further classified as cognitively normal (n = 10) or with HAND (n = 9). Peripheral monocytes and CD4 T cells were phenotyped by flow cytometry and simultaneously isolated for multiplex qPCR-targeted gene expression profiling directly ex vivo. The frequency of HIV-1 RNA-positive cells was estimated by limiting dilution cell sorting. RESULTS Expression of genes and proteins involved in cellular activation and proinflammatory immune responses was increased in monocytes and CD4 T cells from HIV-1-infected relative to uninfected individuals. Gene expression profiles of both CD4 T cells and monocytes correlated with soluble markers of inflammation in the periphery (P

Background: Progesterone belongs to a class of neurosteroids used for the reduction of seizure frequency in patients with refractory epilepsy. However, the pharmacokinetics of progesterone and its active derivative, allopregnanolone, have never been studied in these patients. Objectives: This study was aim to explore the pharmacokinetic parameters of progesterone 400 mg every 12 h, for 3 months, in patients with refractory epilepsy as an add-on therapy to control seizures. Phoenix® WinNonlin® was used to analyse the pharmacokinetic parameters. Results: Twelve patients were recruited. From a therapeutic drug monitoring, the serum progesterone and allopregnanolone levels after taking the first dose of progesterone were characterised by a time to maximum concentration (Tmax) median of 1 and 2.5 h, a maximum concentration (Cmax) median of 274.97 and 3.81 ng/mL, and a minimum concentration (Cmin) median of 56.93 and 1.06 ng/mL, respectively. The median values of the pharmacokinetic parameters of progesterone and allopregnanolone during the steady state were as follows: t1/2 of 2.4 and 2.0 h, Cmax of 964.35 and 8.92 ng/mL, and Cmin of 64.67 and 1.86 ng/mL, respectively. By examining the relationship between the progesterone or allopregnanolone concentrations with seizure-controlling ability, we could identify a responder patient group with 6- to 7-fold higher serum concentrations of progesterone and allopregnanolone than the non-responders. Conclusions: We could establish higher serum levels of both progesterone and allopregnanolone, which could consequently relate to lowering the seizure frequency in patients with refractory epilepsy. The suggested progesterone dose was 400 mg orally every 12 h against refractory epilepsy Trial registration: This study has been registered on the Thai Clinical Trials Registry (No. TCTR20200710005, 10 July 2020)

Objective A randomized, double-blinded, crossover, placebo controlled trial was conducted to evaluate the efficacy and safety of 0.075% capsaicin lotion for treating painful diabetic neuropathy (PDN). Patients and methods PDN subjects were randomized to receive 0.075% capsaicin/placebo for 8 weeks, then crossing over to the other treatment after a 4-weeks washout period. Primary endpoint was the change in visual analog scale score of pain severity. Secondary outcomes were score changes in Neuropathic Pain Scale, short-form McGill Pain Questionnaires, and proportions of patients with pain score reductions of 30% and 50%, and adverse events. Results A total of 42 subjects were enrolled, 27 completed at least an 8-week treatment period. Intention-to-treat analysis showed no significant improvement in pain control with capsaicin lotion compared with placebo for all pain measures and proportion of patients who had 30% or 50% pain relief, respectively. Per protocol analysis were consistent. Capsaicin lotion was well tolerated but local skin reactions were common. Conclusion In patients with PDN, the efficacy of 0.075% capsaicin lotion was similar to placebo but was well tolerated. More work is needed to assess different capsaicin formulations.

We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA.We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression.Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of5 or5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of15 or15.Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.

Background: We aimed to study the efficacy and safety of allopregnanolone which convert from oral micronized progesterone as an adjunctive treatment for Thai patients with refractory status epilepticus.Methods: Adults 18–80 years old who diagnosed with either convulsive or non-convulsive refractory status epilepticus receiving standard AED treatment, intravenous midazolam, for longer than 60 minutes were included. The intervention group received Utrogestran® (micronized progesterone, 200 mg/capsule) via enteric feeding every 8 h for five days. Treatments for RSE were continuing along the clinical trial period. Serum allopregnanolone levels were measured by radioimmunoassay (DetectX® Allopregnanolone Immunoassay Kit; Arbor Assays, Michigan, United States). Control patients were randomly selected from our hospital RSE cohort during 2015–2019. Continuous data were presented as the mean and standard deviation. Discrete data were assessed by number and percentage. The changes in laboratories were analyzed by paired t-test. The difference between groups were compared by independent sample t-test. The Mann-Whitney U test, Chi-square test or Fisher’s exact test were used for non-parametric parameters. A p-value < 0.05 indicated statistical significance. All analyses were performed using SPSS version 26 software (IBM Corp., Armonk, NY).Results: The average duration of refractory status epilepticus after treatment with midazolam plus progesterone (intervention group) and without progesterone until status epilepticus termination was 25.5 and 58.4 hours, (p = 0.004), indicated that allopregnanolone significantly shortens the refractory status epilepticus duration in vivo.Conclusions: Allopregnanolone, produced from oral micronized progesterone, demonstrates efficacy and safety in treating refractory status epilepticus as an adjunctive treatment.Trial registration: This trial was registered in Thai Clinical Trials Registry (TCTR) database. The trial registration number was “TCTR20200717002”, 16 July 2020, retrospectively registered.

Human immunodeficiency virus (HIV) is a rapidly evolving virus, allowing its genetic sequence to act as a fingerprint for epidemiological processes among, as well as within, individual infected hosts. Though primarily infecting the CD4+ T-cell population, HIV can also be found in monocytes, an immune cell population that differs in several aspects from the canonical T-cell viral target. Using single genome viral sequencing and statistical phylogenetic inference, we investigated the viral RNA diversity and relative contribution of each of these immune cell types to the viral population within the peripheral blood. Results provide evidence of an increased prevalence of circulating monocytes harboring virus in individuals with high viral load in the absence of suppressive antiretroviral therapy. Bayesian phyloanatomic analysis of three of these individuals demonstrated a measurable role for these cells, but not the circulating T-cell population, as a source of cell-free virus in the plasma, supporting the hypothesis that these cells can act as an additional conduit of virus spread.

Whereas human immunodeficiency virus (HIV) persists in tissue macrophages during antiretroviral therapy (ART), the role of circulating monocytes as HIV reservoirs remains controversial. Three magnetic bead selection methods and flow cytometry cell sorting were compared for their capacity to yield pure CD14(+) monocyte populations. Cell sorting by flow cytometry provided the purest population of monocytes (median CD4(+) T-cell contamination, 0.06%), and the levels of CD4(+) T-cell contamination were positively correlated with the levels of integrated HIV DNA in the monocyte populations. Using cell sorting by flow cytometry, we assessed longitudinally the infection of monocytes and other cell subsets in a cohort of 29 Thai HIV-infected individuals. Low levels of HIV DNA were detected in a minority of monocyte fractions obtained before and after 1 year of ART (27% and 33%, respectively), whereas HIV DNA was readily detected in CD4(+) T cells from all samples. Additional samples (2 to 5 years of ART) were obtained from 5 individuals in whom monocyte infection was previously detected. Whereas CD4(+) T cells were infected at high levels at all time points, monocyte infection was inconsistent and absent in at least one longitudinal sample from 4/5 individuals. Our results indicate that infection of monocytes is infrequent and highlight the importance of using flow cytometry cell sorting to minimize contamination by CD4(+) T cells. IMPORTANCE The role of circulating monocytes as persistent HIV reservoirs during ART is still controversial. Several studies have reported persistent infection of monocytes in virally suppressed individuals; however, others failed to detect HIV in this subset. These discrepancies are likely explained by the diversity of the methods used to isolate monocytes and to detect HIV infection. In this study, we show that only flow cytometry cell sorting yields a highly pure population of monocytes largely devoid of CD4 contaminants. Using this approach in a longitudinal cohort of HIV-infected individuals before and during ART, we demonstrate that HIV is rarely found in monocytes from untreated and treated HIV-infected individuals. This study highlights the importance of using methods that yield highly pure populations of cells as flow cytometry cell sorting to minimize and control for CD4(+) T-cell contamination.

HIV-associated neurocognitive disorder (HAND) remains a challenge despite antiretroviral therapy (ART), and has been linked to monocyte/macrophage (M/M) migration to the brain. Due to the potential impact of T cell effector mechanisms in eliminating activated/HIV-infected M/M, T cell activation may play a role in the development of HAND. We sought to investigate the relationship between cognition and both CD8+ T cell activation (HLA-DR+/CD38+) and HIV-specific CD8+ T cell responses at the time of HIV diagnosis and 12 months postinitiation of ART. CD8+ T cell activation was increased in HAND compared to cognitive normal (NL) individuals and correlated directly with plasma viral load and inversely with the cognitive status. In addition, Gag-specific cytolytic activity (CD107a/b+) was decreased in HAND compared with NL individuals and correlated with their neurological testing, suggesting a potential role of cytotoxic CD8+ T cells in the mechanism of HAND development.

BACKGROUND: Myeloid activation contributes to cognitive impairment in chronic human immunodeficiency virus (HIV) infection. We explored whether combination antiretroviral therapy (cART) initiation during acute HIV infection impacts CD163 shedding, a myeloid activation marker, and in turn, implications on the central nervous system (CNS). METHODS: We measured soluble CD163 (sCD163) levels in plasma and cerebrospinal fluid (CSF) by enzyme-linked immunosorbent assay in Thais who initiated cART during acute HIV infection (Fiebig stages I–IV). Examination of CNS involvement included neuropsychological testing and analysis of brain metabolites by magnetic resonance spectroscopy. Chronic HIV-infected or uninfected Thais served as controls. RESULTS: We examined 51 adults with acute HIV infection (Fiebig stages I–III; male sex, >90%; age, 31 years). sCD163 levels before and after cART in Fiebig stage I/II were comparable to those in uninfected controls (plasma levels, 97.9 and 93.6 ng/mL, respectively, vs 99.5 ng/mL; CSF levels, 6.7 and 6.4 ng/mL, respectively, vs 7.1 ng/mL). In Fiebig stage III, sCD163 levels were elevated before cART as compared to those in uninfected controls (plasma levels, 135 ng/mL; CSF levels, 10 ng/mL; P < .01 for both comparisons) before normalization after cART (plasma levels, 90.1 ng/mL; CSF levels, 6.5 ng/mL). Before cART, higher sCD163 levels during Fiebig stage III correlated with poor CNS measures (eg, decreased N-acetylaspartate levels), but paradoxically, during Fiebig stage I/II, this association was linked with favorable CNS outcomes (eg, higher neuropsychological test scores). After cART initiation, higher sCD163 levels during Fiebig stage III were associated with negative CNS indices (eg, worse neuropsychological test scores). CONCLUSION: Initiation of cART early during acute HIV infection (ie, during Fiebig stage I/II) may decrease inflammation, preventing shedding of CD163, which in turn might lower the risk of brain injury.

Monocytes play a vital role in HIV-associated neurocognitive disorder (HAND), postulated to transport HIV into the brain and secrete pro-inflammatory cytokines. We analyzed cytokines released by cultured peripheral blood mononuclear cells enriched with the CD14 marker isolated from HIV-infected individuals with HAND and normal cognition (NC) in combination antiretroviral therapy naive and after 1 year on treatment. Interleukin-8 and monocyte chemoattractant protein-1 levels were higher in HAND compared with NC at baseline (P = 0.002 and P < 0.0001). These cytokines remained higher in HAND patients 1 year after combination antiretroviral therapy and were significant when NC patients who were initially HAND were excluded (P = 0.012 and P = 0.002). Both correlated with baseline CD14 peripheral blood mononuclear cell HIV DNA levels supporting the role of HIV DNA reservoir size and monocyte cytokines in HAND persistence.

HIV DNA in monocytes has been linked to HIV-associated neurocognitive disorders (HAND), however, characterization of monocyte subsets associated with HAND remains unclear. We completed a prospective study of antiretroviral therapy-naïve, HIV-infected Thais, with varying degrees of cognitive impairment, compared to HIV-uninfected controls. Monocyte subsets' CCR2, CCR5 and CD163 expression were profiled and inflammatory markers in plasma and cerebrospinal fluid (CSF), measured. Lower numbers of CCR2(+)non-classical monocytes were associated with worse neuropsychological test performance (r=0.43, p=0.024). CCR2(+)non-classical monocyte count inversely correlated with CSF neopterin (r=-0.43, p=0.035) and plasma TNF-α levels (r=-0.40, p=0.041). These data benchmark CCR2(+)non-classical monocytes as an independent index of cognitive impairment.

The Epworth Sleepiness Scale (ESS), Sleep Apnea Scale of Sleep Disorders Questionnaire (SA-SDQ), and Pittsburgh Sleep Quality Index (PSQI) are widely used in English speaking countries for sleep problem screening. However, there is no officially validated Thai-version of sleep questionnaires available.To provide standard Thai version of three sleep questionnaires and find cut-off level to screening sleep problems in Thai population.We used Mapi Research Institute Methods for translation from original language to Thai questionnaire. Then, test-retest reliability analysis was performed. Finally, we collected data from patients who underwent polysomnography in Phramongkutklao Sleep Lab Centre between June and August 2011. Cut-off value to screen population at risk for sleep-related disorder was researched.The questionnaires were translated with very good inter-rater agreement. Cut-off of ESS, SA-SDQ, and PSQI suggested sleep disorders would be 9, 27, and 6.5 respectively.Sleep disorder questionnaires including ESS, SA-SDQ, and PSQI were translated into Thai with high validity, reliability, and accuracy.

Epilepsy surgery has been established for treatment of drug-resistant focal epilepsy. We aimed to determine long-term outcomes of epileptic surgery in various aspects including seizure outcome, quality of life, and psychosocial consequences after surgery.A single center, cross-sectional study was conducted. The patients with drug-resistant focal epilepsy who underwent epileptic surgery for at least one year were recruited.Thirty-seven adult drug-resistant epilepsy patients after epileptic surgery were enrolled with an average follow-up period of 5.8 years. Twenty-three (62.2%) had temporal lobe epilepsy (TLE) and 14 (37.8%) had neocortical epilepsy. Four were (10.8%) compatible with lesional negative refractory epilepsy. Hippocampal sclerosis was the most common etiology (45.9%), followed by focal cortical dysplasia/gliosis (21.6%) and brain tumor (21.6%). The three commonest postoperative complications were any medical illnesses (18.9%), memory impairment (18.9%), and visual filed defect (13.5%). Twenty patients (54.1%) had no complications. Seizure outcomes, employment status, quality of life, depression, frank psychosis, and number of antiepileptic drug (AED) between pre- and post-surgical period (interviewing time) were compared. Engel Class I (seizure freedom) was persistently achieved in 19 (51.4%) patients. There were nine (24.3%) patients in Engel Class II, eight (21.6%) in Engel Class III, and one (2.7%) in Engel Class IV. Seizure outcome, quality of life, and self-assessment were improved after epileptic surgery at any age groups, duration of epilepsy, epileptogenic zone, and side of operation. In some subgroups, it was found that income was increased and number of AED was reduced. However, depression and frank psychosis did not change the outcome. On self-assessment, global impression of change in memory showed 27% improvement and 32.4% no change. For language and communication skills, 29.7% was improved but 21.6% was worsened.In this longitudinal study, epilepsy surgery showed improvement in seizure control, quality of life, and some neuropsychological aspects.

This study aimed to determine the effects of human immunodeficiency virus (HIV) on brain structure in HIV-infected individuals with and without HIV-associated neurocognitive disorders (HAND). Twenty-nine HIV-uninfected controls, 37 HIV+, treatment-naïve, individuals with HAND (HIV+HAND+; 16 asymptomatic neurocognitive impairment (ANI), 12 mild neurocognitive disorder (MND), and 9 HIV-associated dementia HAD), and 37 HIV+, treatment-naïve, individuals with normal cognitive function (HIV+HAND-) underwent magnetic resonance imaging (MRI) and neuropsychological assessment. The HIV-infected participants had a mean (SD) age of 35 (7) years, mean (interquartile range (IQR)) CD4 count of 221 (83-324), and mean (IQR) log10 plasma viral load of 4.81 (4.39-5.48). Six regions of interest were selected for analyses including total and subcortical gray matter, total white matter, caudate, corpus callosum, and thalamus. The HIV+/HAND+ group exhibited significantly smaller brain volumes compared to the HIV-uninfected group in subcortical gray and total gray matter; however, there were no statistically significant differences in brain volumes between the HIV+HAND+ and HIV+HAND- groups or between HIV+/HAND- and controls. CD4 count at time of combination antiretroviral therapy (cART) initiation was associated with total and subcortical gray matter volumes but not with cognitive measures. Plasma viral load correlated with neuropsychological performance but not brain volumes. The lack of significant differences in brain volumes between HIV+HAND+ and HIV+HAND- suggests that brain atrophy is not a sensitive measure of HAND in subjects without advanced immunosuppression. Alternatively, current HAND diagnostic criteria may not sufficiently distinguish patients based on MRI measures of brain volumes.

In May 2012, the Division of AIDS Research at the National Institute of Mental Health (NIMH) organized the "Global NeuroAIDS Roundtable" in conjunction with the 11th International Symposium on Neurovirology and the 2012 Conference on HIV in the Nervous System. The meeting was held in New York, NY, USA and brought together NIMH-funded investigators who are currently working on projects related to the neurological complications of AIDS (NeuroAIDS) in Africa, Asia, Eastern Europe, and Latin America in order to provide an opportunity to share their recent findings and discuss the challenges encountered within each country. The major goals of the roundtable were to evaluate HIV-associated neurocognitive impairment and determine if it may be directly attributable to distinct HIV subtypes or clades and to discuss the future priorities for global NeuroAIDS research. At the "Global NeuroAIDS Roundtable", presentations of preliminary research indicated that HIV-associated neurocognitive impairment is prevalent in all countries examined regardless of which HIV clade is present in the region. The only clear-cut difference between HIV-1 clades was in relation to subtypes A and D in Uganda. However, a key point that emerged from the discussions was that there is an urgent need to standardize neurocognitive assessment methodologies across the globe before definitive conclusions can be drawn regarding the relationship between HIV clade diversity and neuropathogenesis. Future research directions were also discussed at the roundtable with particular emphasis on the potential of viral and host factor molecular interactions to impact the pathophysiology of HIV-associated neurocognitive disorders (HAND) from a global perspective. © 2013 Journal of NeuroVirology, Inc. (outside the USA).

ObjectiveTo evaluate differences in soluble inflammatory markers between chronically HIV-infected men and women, with or without cognitive impairment, and in response to treatment.DesignSoluble biomarkers were measured in cryopreserved plasma and cerebrospinal fluid (CSF) of 60 treatment-naïve individuals (25 men and 35 women) with chronic HIV infection and 18 HIV-uninfected controls (9 men and 9 women) from Thailand. Following enrollment, participants began combination antiretroviral therapy and were evaluated for expression of these markers after 48 weeks.MethodsPlasma and CSF levels of 19 soluble biomarkers (IFN-γ, TNFα, TNF-RII, IL-1α, IL-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-15, MCP-1, t-Tau, IP-10, neopterin, IFNα, I-FABP, and sCD14) were measured using either a multiparameter or standard ELISA assay.ResultsPrior to combination antiretroviral therapy, women with impaired cognition had elevated levels of neopterin and TNF-RII compared with women with normal cognition in both the plasma and CSF; however, levels did not differ between cognitively impaired or normal men. In a secondary outcome-hypothesis generating analysis, sex differences were also pronounced in plasma levels of MCP-1, IL-10, I-FABP, and sCD14 in response to treatment. Neopterin, IP-10, TNFα, TNF-RII, IFNα, MCP-1, IL-8, I-FABP, and sCD14 plasma levels remained elevated following 48 weeks of therapy in both sexes compared with uninfected controls.ConclusionWe provide evidence of sustained immune activation after 48 weeks of treatment and identify possible sex differences in biomarkers previously linked to cognitive impairment, chronic inflammation, and gut integrity that may contribute to immunological differences between sexes in relationship to disease progression and response to therapy.

To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome.Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) 8 were randomly allocated intofour groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count.Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPVwas reduced and NIHSS, mRS were improved in every studied group. Clopidogrel sign ficantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others.Every type of antiplatelets included in this study reduced MPV NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most.

HIV can infect the brain and impair central nervous system (CNS) function. Combination antiretroviral therapy (cART) has not eradicated CNS complications. HIV-associated neurocognitive disorders (HAND) remain common despite cART, although attenuated in severity. This may result from a combination of factors including inadequate treatment of HIV reservoirs such as circulating monocytes and glia, decreased effectiveness of cART in CNS, concurrent illnesses, stimulant use, and factors associated with prescribed drugs, including antiretrovirals. This review highlights recent investigations of HIV-related CNS injury with emphasis on cART-era neuropathological mechanisms in the context of both US and international settings.

(Headache 2011;51:52-63) Objective.— To evaluate the efficacy, safety, and optimum dose of a highly purified Clostridium botulinum type A toxin-hemagglutinin complex (Dysport) for migraine prophylaxis. Background.— Botulinum toxin type-A has demonstrated good efficacy in several open-label studies of patients with migraine, involving either individualized or standardized protocols, although data from placebo-controlled trials have been conflicting. Methods.— A 12-week, double-blind, randomized trial of Dysport (120 or 240 units) vs placebo was conducted in 6 centers in Thailand to evaluate the efficacy, safety, and optimum dose of botulinum toxin type-A (Dysport) for migraine prophylaxis. A total of 128 patients with migraine without aura were enrolled. The primary end point was the change in the mean number of migraine attacks per 4-week period from the pre-treatment period to 8-12 weeks post injection. Secondary efficacy measures included the change in the mean total intensity score from the pre-treatment period to 8-12 weeks, the investigator and patient global assessments of change at each visit compared with pre-treatment, and Migraine Disability Assessment and Short Form-36 scores. Results.— Change in number of migraine attacks from pre-treatment to weeks 8-12 was not significantly different. There was a greater improvement in total intensity score at weeks 8-12 with Dysport-240 (not significant), and interim visit data showed that this was significant at weeks 0-4 (P = .03 Dysport-240 vs placebo). The mean duration of headache during weeks 0-4 was lower with Dysport-240 (P = .04 vs placebo). Improvements in patient and investigator global assessments of change between weeks 0-4 and 8-12 were significant for the Dysport-240 group (both P

In this study we describe the electrophysiological findings in botulism patients with neuromuscular respiratory failure from major botulism outbreaks in Thailand. High-rate repetitive nerve stimulation testing (RNST) of the abductor digiti minimi (ADM) muscle of 17 botulism patients with neuromuscular respiratory failure showed mostly incremental responses, especially in response to >20-HZ stimulation. In the most severe stage of neuromuscular respiratory failure, RNST failed to elicit a compound muscle action potential (CMAP) of the ADM muscle. In the moderately severe stage, the initial CMAPs were of very low amplitude, and a 3-HZ RNST elicited incremental or decremental responses. A 10-HZ RNST elicited mainly decremental responses. In the early recovery stage, the initial CMAP amplitudes of the ADM muscle improved, with initially low amplitudes and an incremental response to 3- and 10-HZ RNSTs. Improved electrophysiological patterns of the ADM muscle correlated with improved respiratory muscle function. Incremental responses to 20-HZ RNST were most useful for diagnosis. The initial electrodiagnostic sign of recovery following treatment of neuromuscular respiratory failure was an increased CMAP amplitude and an incremental response to 10-20-HZ RNST. Muscle Nerve 40: 271-278, 2009.

SCN1A is the most clinically relevant epilepsy gene and is associated with generalized epilepsy and febrile seizure plus (GEFS+) and Dravet syndrome. We postulated that earlier onset of febrile seizures in the febrile seizure (FS) and febrile seizure plus (FS+) phenotypes may occur in the presence of a SCN1A mutation. This was because of the age-related onset of Dravet syndrome, which typically begins in the first year of life. We found that patients with FS and FS+ with SCN1A mutations had earlier median onset of febrile seizures compared to the population median. Patients with GABRG2 mutations had a similar early onset in contrast to patients with SCN1B mutations where onset was later. This study is the first to demonstrate that a specific genetic abnormality directly influences the FS and FS+ phenotype in terms of age of onset. Refereed/Peer-reviewed

The extent to which highly active antiretroviral therapy (HAART) era cognitive disorders are due to active processes, incomplete clearance of reservoirs, or comorbidities is controversial. This study aimed to determine if immunologic and virologic factors influence cognition after first-time HAART in Thai individuals with HIV-associated dementia (HAD) and Thai individuals without HAD (non-HAD).Variables were captured longitudinally to determine factors predictive of degree of cognitive recovery after first-time HAART. Neuropsychological data were compared to those of 230 HIV-negative Thai controls.HIV RNA and CD4 lymphocyte counts were not predictive of HAD cross-sectionally or degree of cognitive improvement longitudinally. In contrast, baseline and longitudinal HIV DNA isolated from monocytes correlated to cognitive performance irrespective of plasma HIV RNA and CD4 lymphocyte counts pre-HAART (p0.001) and at 48 weeks post HAART (p0.001). Levels exceeding 3.5 log(10) copies HIV DNA/10(6) monocyte at baseline distinguished all HAD and non-HAD cases (p0.001). At 48 weeks, monocyte HIV DNA was below the level of detection of our assay (10 copies/10(6) cells) in 15/15 non-HAD compared to only 4/12 HAD cases, despite undetectable plasma HIV RNA in 26/27 cases. Baseline monocyte HIV DNA predicted 48-week cognitive performance on a composite score, independently of concurrent monocyte HIV DNA and CD4 count (p0.001).Monocyte HIV DNA level correlates to cognitive performance before highly active antiretroviral therapy (HAART) and 48 weeks after HAART in this cohort and baseline monocyte HIV DNA may predict 48-week cognitive performance. These findings raise the possibility that short-term incomplete cognitive recovery with HAART may represent an active process related to this peripheral reservoir.

Objective Combination antiretroviral therapy (cART) can suppress plasma HIV RNA to undetectable levels; yet reports indicate persistent HIV-associated neurocognitive disorders (HAND) among treated individuals. We sought to investigate imaging correlates of incomplete cognitive recovery among individuals with chronic HIV. Methods We used single voxel proton magnetic resonance spectroscopy in 4 regions of the brain to measure changes in neuronal and glia biomarkers in cART-naive subjects before (n = 59, 27 with HAND) and after 12 months of cART. Results At baseline, we observed elevated total choline (CHO) in the basal ganglia (BG, P = 0.002) and in the posterior cingulate gyrus (PCG, P = 0.022) associated with HIV infection. Myo-inositol (MI) was elevated in the frontal white matter (FWM, P = 0.040). N-acetylaspartate was elevated in the BG (P = 0.047). Using a mixed model approach among all HIV-infected individuals, at 6 months, we observed decreased n- acetylaspartate in FWM (P = 0.031), decreased creatine in PCG (P = 0.026) and increased MI in frontal gray matter (FGM, P = 0.023). At 12 months, we observed an increase in BG MI (P = 0.038) and in FGM (P = 0.021). Compared to those with normal cognition, HAND cases had higher FGM MI (P = 0.014) at baseline. At 12 months, individuals that remained cognitively impaired compared with those without HAND exhibited elevated CHO in the PCG (P = 0.018) and decreased glutamate in both FWM (P = 0.027) and BG (P = 0.013). Conclusions cART started during chronic HIV is associated with reduced neuronal-glia and inflammatory markers. Alterations in CHO are noted among individuals who remain impaired after 12 months of cART.

Background. It is unknown whether neuronal injury begins during acute human immunodeficiency virus (HIV) infection, and whether immediate initiation of combination antiretroviral therapy (cART) prevents neuronal injury. Methods. Cerebrospinal fluid (CSF) neurofilament light chain (NFL), a measure of axonal injury, was assessed before and after cART initiation in individuals starting treatment during acute or chronic HIV infection. Nonparametric statistics examined relationships between NFL and disease progression, neuroinflammation, and cognitive performance. Results. Before treatment, subjects with acute infection had lower CSF NFL levels, with elevations for their age in 1 of 32 subjects with acute infection (3.1%) and 10 of 32 with chronic infection (31%) (P = .006). This persisted after cART initiation, with 1 of 25 acute (4%) and 4 of 9 chronic subjects (44%) showing elevated NFL levels (P = .01). In acute infection, pre-cART NFL levels were inversely correlated with proton magnetic resonance spectroscopic findings of N-acetylaspartate/creatine in frontal gray matter (r = −0.40; P = .03), frontal white matter (r = −0.46; P = .01), and parietal gray matter (r = −0.47; P = .01); correlations persisted after treatment in the frontal white matter (r = −0.51; P = .02) and parietal gray matter (r = −0.46; P = .04). Conclusions. CSF NFL levels are not elevated in untreated acute HIV infection or after 6 months of immediately initiated cART but are abnormal in chronic HIV infection before and after treatment. In acute HIV infection, CSF NFL levels are inversely associated with neuroimaging markers of neuronal health.

Background Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure. Methods We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured. Results Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02). Conclusions Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.

Non-motor symptoms (NMS) ofParkinson's disease (PD) have been recently recognized to be as disabling as motor symptoms in PD. However these symptoms are still under recognized causing delay in treatment and inadequate management. This study aimed to identify NMS in Thai PD patients using the NMS screening questionnaire (NMSQuest).Patients with idiopathic Parkinson's disease visiting the neurology clinic in 2008 were enrolled. NMSQuest-Thai version (NMSQ-T) was applied to patients to identify NMS.Collected data from questionnaires completed by 165 probable idiopathic PD was analyzed. The demographic profiles showed mean age of 68.6 years with mean disease duration 5.4 years, and male 56.4%. Patients had HoehnYahrstaging, stage-2: 43%, stage-3: 24.8%, stage-I: 24.2% and stage-4: 7.9%. The average dosage oflevodopa was 456.4 mg/d. Mean total NMSQ-T score was 9.5. Most prevalent of non-motor symptom was nocturia (64.2%). The domains which gained most positive answers were urinary domain (54.55%). Inter-domain correlations were significantly found in all, except the sexual domain. Multivariate analysis revealed the duration ofPD and stages were significantly correlated with the total score ofNMS. Only three percent denied having any non-motor symptoms.Almost all Thai PD had NMS. Urinary domain is the most prevalent in our series. Screening using NMSQ-Tto recognize NMS would be a helpful tool to improve the quality of life in Thai Parkinson 's disease.

Sleepiness is a common complaint in epilepsy. Also obstructive sleep apnea (OSA) is increasingly detected and would affect the epilepsy prognosis. We aimed to determine the frequency and predictors of sleepiness and OSA in epileptic patients.This was a cross-sectional descriptive study using Epworth Sleepiness Scale questionnaire (ESS) and Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) to identify excessive daytime sleepiness and OSA in our consecutive epileptic patients in Neurology out-patient clinic.Overall 113 patients (male 55%) answered a personal survey and completed ESS and SA-SDQ. Mean age was 47 years (range 15-93). Average body mass index (BMI) was 24. Excessive daytime sleepiness (ESS 10) was demonstrated in 37%, and the prevalence of OSA diagnosed by using SA-SDQ was 20% (male 18%, female 22%). OSA were identified 68% among individuals whose BMI of more than 25, which was significant higherfi-equency than in the nomnnal BMI group (32%). The predictors of having OSA were older age and higher BMI. Epworth Sleepiness Scale score was also higher in the OSA group than in non-OSA group.Excessive daytime sleepiness was identified around one third ofour epileptic individutals. Twenty percent had met the questionnaire criteria of having OSA. Overweight was the most important and modifiable risk factor ofOSA.

To identify the frequency of behavioral and psychological symptoms of dementia (BPSD) and to explore the different characteristics between subgroup and severity of dementia.Sixty-seven patients with Alzheimer's disease, vascular dementia, and mixed dementia were recruited to our cross-sectional study. Neuropsychiatric batteries including the Mini Mental Status Examination-Thai 2002, Thai Geriatric Depression Scale, 23 items from Alzheimer's Disease co-operative Study activities of daily living inventory, Behavioralpathology in Alzheimer's disease rating scale, and Pittsburg Sleep Quality Index were tested.The most common behavioral and psychological symptoms of dementia (BPSD) were sleep problems (100%), paranoid/delusion (59.7%), diurnal disturbance (49.2%) and aggressiveness (46.3%). Hallucination and affective problems were more severe in AD than in VaD/mixed dementia. Sleep problems were identified more severe in mild dementia than moderate-to-severe dementia. With longer duration of having dementia, exceptfor affective problem, there was no diffemence in behavioral and psychological symptoms observed compared to the shorter dementia group.Behavioral and psychological symptoms were very common in Alzheimer disease, vascular dementia, and mixed dementia. Since these symptoms cause cognitive and functional decline, institutionalization, caregiver distress and increase direct costs ofcare, the problem must be identified and addressed.

Author(s): Kallianpur, Kalpana J; Valcour, Victor G; Lerdlum, Sukalaya; Busovaca, Edgar; Agsalda, Melissa; Sithinamsuwan, Pasiri; Chalermchai, Thep; Fletcher, James LK; Tipsuk, Somporn; Shikuma, Cecilia M; Shiramizu, Bruce T; Ananworanich, Jintanat; SEARCH 011 study group | Abstract: ObjectiveTo examine associations between regional brain volumes and HIV DNA in peripheral CD14 cells (monocytes) among HIV-infected individuals naive to combination antiretroviral therapy (cART).DesignA prospective study of HIV-infected Thai individuals who met Thai national criteria for cART initiation. Enrolment was stratified by HIV DNA in a blinded fashion.MethodsCD14 cells were isolated from peripheral mononuclear cells to high purity (median 91.4% monocytes by flow cytometry), and HIV DNA was quantified by multiplex real-time PCR. Baseline regional brain volumes obtained by T1-weighted 1.5-Tesla MRI were compared between HIV DNA groups using analysis of covariance (ANCOVA).ResultsWe studied 60 individuals with mean (SD) age of 34.7 (7.0) years, CD4 T-lymphocyte count of 232 (137) cells/μl and log10 plasma HIV RNA of 4.8 (0.73). Median (interquartile range, IQR) HIV DNA copy number per 10 CD14 cells was 54 (102). Using our previously determined optimal cut-point of 45 copies/10 cells for this cohort, a threshold value above which CD14 HIV DNA identified HIV-associated neurocognitive disorders (HANDs), we found that CD14 HIV DNA ≥ 45 copies/10 cells was associated with reduced volumes of the nucleus accumbens (P=0.021), brainstem (P=0.033) and total gray matter (P=0.045) independently of age, CD4 cell count and intracranial volume.ConclusionHIV DNA burden in CD14 monocytes is directly linked to brain volumetric loss. Our findings implicate peripheral viral reservoirs in HIV-associated brain atrophy and support their involvement in the neuropathogenesis of HAND, underscoring the need for therapies that target these cells.

There were errors in multiple affiliations for multiple authors. Please see the following correct list of authors and affiliations: Victor G. Valcour 1,2*,Jintanat Ananworanich, 3,4,5,6, Melissa Agsalda 6, Napapon Sailasuta 7, Thep Chalermchai 3, Alexandra Schuetz 8, Cecilia Shikuma 6, Chin-Yuan Liang 6, Supunee Jirajariyavej 9, Pasiri Sithinamsuwan 10, Somporn Tipsuk 3, David B. Clifford 11, Robert Paul 12, James L. K. Fletcher 3, Mary A. Marovich 13, Bonnie M. Slike 14, Victor DeGruttola 15, Bruce Shiramizu 6 1. Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA USA 2. Division of Geriatric Medicine, Department of Medicine, University of California, San Francisco CA, USA 3. SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand 4. HIV-NAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand 5. Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand 6. Hawaii Center for AIDS, University of Hawaii, Honolulu HI USA 7. Huntington Medical Research Institutes, Pasadena CA USA 8. Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 9. Taksin Hospital, Bangkok, Thailand 10. Division of Neurology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand 11. Department of Neurology, Washington University, St. Louis MO USA 12. Department of Psychology, University of Missouri, St. Louis MO, USA 13. Division of AIDS, National Institute of Allergy and Infection Diseases of the National Institutes of Health, Bethesda MD, USA 14. US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring MD, USA 15. Department of Biostatistics, Harvard School of Public Health, Boston MA, USA

Objectives:Cognitive impairment remains frequent in HIV, despite combination antiretroviral therapy (cART). Leading theories implicate peripheral monocyte HIV DNA reservoirs as a mechanism for spread of the virus to the brain. These reservoirs remain present despite cART. The objective of this study was to determine if the level of HIV DNA in CD14+ enriched monocytes predicted cognitive impairment and brain injury.Methods:We enrolled 61 cART-naïve HIV-infected Thais in a prospective study and measured HIV DNA in CD14+ enriched monocyte samples in a blinded fashion. We determined HAND diagnoses by consensus panel and all participants underwent magnetic resonance spectroscopy (MRS) to measure markers of brain injury. Immune activation was measured via cytokines in cerebrospinal fluid (CSF).Results:The mean (SD) age was 35 (6.9) years, CD4 T-lymphocyte count was 236 (139) and log10 plasma HIV RNA was 4.8 (0.73). Twenty-eight of 61 met HAND criteria. The log10 CD14+ HIV DNA was associated with HAND in unadjusted and adjusted models (p = 0.001). There was a 14.5 increased odds ratio for HAND per 1 log-value of HIV DNA (10-fold increase in copy number). Plasma CD14+ HIV DNA was associated with plasma and CSF neopterin (p = 0.023) and with MRS markers of neuronal injury (lower N-acetyl aspartate) and glial dysfunction (higher myoinositol) in multiple brain regions.Interpretation:Reservoir burden of HIV DNA in monocyte-enriched (CD14+) peripheral blood cells increases risk for HAND in treatment-naïve HIV+ subjects and is directly associated with CSF immune activation and both brain injury and glial dysfunction by MRS. © 2013 Valcour et al.

Although HIV-Associated Dementia (HAD) occurs in less than 5% of individuals with access to combination antiretroviral therapy (cART), rates of milder forms of HIV-Associated Neurocognitive Disorder (HAND) are much higher. We sought to define an optimal cut-point for the International HIV-Dementia Scale (IHDS) in Thailand for the identification of symptomatic HAND, defined as both HAD and Mild Neurocognitive Disorder (MND). We then sought to determine if adding a simple test from a larger neuropsychological battery could improve the performance characteristics for identifying symptomatic HAND. In this study 75 seropositive adults in Bangkok, Thailand, subjects completed neuropsychological tests and underwent a full neurological assessment. HAND diagnoses were determined by consensus conference using the 2007 Frascati criteria, blinded to the IHDS results. The optimal IHDS cut-point was determined by Receiver Operating Characteristic analysis with cross-validation. Individual neuropsychological tests were then evaluated and combined with the IHDS to test performance characteristics. The IHDS was poor at detecting symptomatic HAND at the optimized cut-point of ≤10 (sensitivity: 53.3%, specificity: 89.8%). The Trail Making Test A was most effective in improving performance characteristics when combined with the IHDS, with net sensitivity of 86% and specificity of 79%. In this setting, the IHDS performed poorly in identifying symptomatic HAND, but was substantially improved by the addition of Trail Making Test A, which typically requires less than two minutes to complete. This combination should be validated in a larger setting since it may address the critical need for HAND screening instruments in international settings.

International studies of HIV-associated neurocognitive disorder (HAND) are needed to determine the viral and host factors associated with cognitive impairment particularly as more than 80% of HIV+ subjects reside in resource-limited settings. Recent diagnostic nomenclature of HAND requires comparison of cognitive performance specifically to local normative data. To evaluate this need for local norms, we compared normative data obtained locally in Thailand to Western norms. The current study examined cognitive performance in 477 seronegative Thai participants (male = 211, female = 266) who completed a battery of tests sensitive to cognitive changes in HIV. The cohort was divided into three age brackets (20-34; 35-49; 50-65 years) and four educational levels (no education or primary education, less than secondary certificate, high-school/associates degree, bachelor's degree or greater). The Thai cohort was compared (using analysis of covariance, ANCOVA) on a number of measures to a seronegative US cohort (n = 236; male = 198, female = 38) to examine cultural differences in performance. Normative data are provided with age and education stratification. The Thai and US groups performed significantly differently on all neuropsychological measures with the exception of verbal fluency. The Thai group performed better on measures of verbal learning (p < .001) and memory (p < .001) and measures of psychomotor speed (p < .001). Education was a more powerful predictor of performance in the Thai cohort than in the US group. These results highlight the continued need for the development of normative data within local populations. The use of Western norms as a comparison group could lead to inaccurate identification of HAND in culturally distinct groups.

Background : There are limited data on HIV-associated neurocognitive disorders (HANDs) from resource-constraint region and few studies have firm documentation of duration of treatment and suppression of plasma virus. This study aimed to estimate the prevalence of HIV-related cognitive deterioration among HIV-infected patients who were on stable ART and to describe the pattern of neurocognitive impairment (NCI), daily life disturbance and associated factors. Methods: This was a cross-sectional evaluation of cognition in a sample of HIV adults at HIV-NAT, the Thai Red Cross AIDS Research Centre with data captured over a 6-month period. The Montreal Cognitive Assessment (MoCA), International HIV Dementia Scale (IHDS) and Activities of Daily Living Questionnaire (ADLQ) scale were administered. NCI was defined as a score of ≤10 on the IHDS or

Kleine-Levin syndrome (KLS) is a rare disorder characterized by periodic hypersomnia, cognitive and behavioral disturbances. Other unique symptoms in KLS are megaphagia, hypersexuality and some psychiatric disturbances such as compulsion and depression. Definite diagnosis requires the elimination of other potential etiologies. We reported a typical case of KLS in a young Thai man who suffered from seven episodes of periodic hypersomnia within 1.5 years and eventually he was diagnosed with Kleine-Levin syndrome after excluding known possible neurological conditions and sleep disorders.

Parkinson's disease (PD) is one of the neurogenic etiologies of orthostatic hypotension, a non-motor symptoms complex, that tends to be under-recognized and under-treated leading to a major cause of disability for PD patients. This complication is associated with one or recurrent falls causing mortality and morbidity. To the authors' knowledge, there is no study about this condition in Thai PD population. The authors therefore aimed to determine the frequency, clinical and risk factors of orthostatic hypotension in PD patients treated in Phramongkutklao Hospital.The authors enrolled consecutive patients with idiopathic PD over a 10-month period. Supine and standing blood pressure (BP) were measured sequentially as the standard techniques. Orthostatic hypotension (OH) was diagnosed if there was a reduction in systolic or diastolic BP of at least 20 or 10 mmHg respectively within 3 minutes after standing. The authors analyzed for the frequency of this condition as well as determined the risk factors between the OH and non-OH groups.The number of patients enrolled was 82 with the mean age of 69 years. The median duration of PD was 4 years. Eighty-five percent were in HoehnYahr stage 1-3. Thirty-three patients (40.2%) had orthostatic hypotension and 70% of them were asymptomatic. By univariate and multivariate analysis, the risk factors for this condition were the longer duration of PD diagnosis, the more advanced staging and the use of selegiline.The frequency of orthostatic hypotension among the present PD was 40.2%. The longer duration of disease, the more advanced stage of Parkinson's disease and selegiline usage were the factors associated with this non-motor condition.

To study prevalence of depression in poststroke survivors in Phramongkutklao Hospital and factors associated with depression.From 150 stroke survivors, therefor 101 patients who met inclusion criteria. These subjects were screened with Thai Geriatric Depressive Scale (TGDS) and interviewed. Demographic data that would effect depression were evaluated.During 9 months of studying period, 101 of 150 patients diagnosed with poststroke survivors were eligible. The prevalence of depression was 46.53%. Severity of depression were mild depression 20.79%, moderate 18.81% and severe depression 6.93%. There were no statistically significant among sex, diabetes mellitus, hypertension, smoking, hyperlipidemia, and site of stroke between depression and non-depression groups. Risk factors for severe poststroke depression were younger age, duration within one year after stroke onset and history of coronary artery disease.The prevalence of poststroke depression was 46.53%. Risk factors of severe depression were younger age, duration within one year of stroke onset and history of coronary artery disease.

To determine the clinical outcomes of an aggressive combined cooling technique for exertional heatstroke in Thailand.We analyzed patients who were diagnosed with exertional heatstroke between 1995 and 2007. Outcomes were assessed both in hospital and at 3 months follow-up.Twenty-eight cases of exertional heatstroke presented to Phramongkutklao Army Hospital over 12 years. All patients developed multiorgan dysfunction and encephalopathy. Twenty-four cases had acute renal failure, 7 of whom required dialysis. Disseminated intravascular coagulation (DIC) was detected in 9 patients (32.1%). In-hospital mortality was 7.1%. Most survivors recovered with nearly normal organ function. However, 9 exhibited prolonged neurologic dysfunction and 2 had chronic renal dysfunction requiring hemodialysis. At 3-month follow-up, neurologic and renal dysfunction in those patients persisted. Higher serum prothrombin time and DIC correlated to fatality. The patients whose core body temperature achieved 38 degrees C within 3 hours revealed a significantly lower DIC and twice as low in the frequency of poor outcome than the patients cooled longer than 3 hours to reduce core body temperature to 38 degrees C.Despite early recognition and aggressive combined cooling, exertional heatstroke remains associated with multiorgan dysfunction. However, our 7.1% in-hospital mortality rate was low compared to previous studies. Early diagnosis and prompt treatment are critical.

To the Editor: HIV-associated sensory neuropathy (HSN) encompasses distal sensory polyneuropathy and antiretroviral toxic neuropathy with clinical features between the two that are indistinguishable.1 In the absence of antiretroviral (ARV) medications, HSN is as frequent as 30% among patients with AIDS.2 Immunosuppression and higher plasma HIV RNA levels increase both risk and severity.3 Dideoxynucleoside reverse transcription inhibitors (dNRTIs) add additional risk that may induce or unmask underlying neuropathy.4 Although less frequently employed in developed countries, dNRTIs, particularly stavudine (d4T), are commonly used in developing countries due to low cost. Here, HSN rates after initiation of predominantly d4T-containing ARV therapy range from 6% to 20.7%, with one Thai study reporting 6.9% after 48 weeks of treatment.5–8 We present a cross-sectional study of HSN from an outpatient infectious diseases (ID) clinic at Phramongkutklao Medical Center in Bangkok, Thailand. Approved by the Phramongkutklao Medical Center Institutional Review Board, this study screened 118 cases and enrolled 100 subjects between January and July 2006 by approaching all outpatients attending the clinic in consecutive order on days when the neurology staff was available (approximately 2 days of each month). Subjects had to be 14 years and above with documented HIV. Exclusion criteria were inability to sign consent or the presence of confounding factors known to potentially influence neuropathy (eg, neurotoxic chemotherapeutic treatment, diabetes, alcoholism, and chronic renal failure). History of HIV, comorbid illnesses, opportunistic infections, illicit drug use, and medication profiles including ARV history were obtained from chart review and participant interview. When available within 3 months before entry, CD4 lymphocyte counts (85/100) and plasma HIV RNA (37/100) were recorded. The neurological evaluation utilized standardized methodology as applied in the AIDS Clinical Trials Group (ACTG) noting proximity of distal sensory impairments in pinprick, temperature, vibration, and joint position at the great toes, ankles, and knees, bilaterally providing categorical scores from 0 to 4 based on sensory levels.9 Symptoms (paresthesias, numbness, and neuropathic pain) were each rated on a similar 4-point scale. We defined possible HSN as decreased sensation of at least 1 modality in both lower extremities or a decrease or absence of ankle reflexes when compared with the patellar reflex and probable HSN more stringently as decreased sensation of at least 1 modality in both lower extremities and a decrease or absence of ankle reflexes. Subjects meeting criteria for HSN who had symptoms were categorized as symptomatic HSN. Differences between subjects with and without HSN were assessed by Mann-Whitney test for 2 independent samples for continuous variables and by χ2 test or Fisher exact test for dichotomous variables. Most subjects had advanced HIV disease with a median (interquartile range) CD4 count of 132 (24–320) cells per deciliter, and 37% had a past AIDS-defining opportunistic illness, most frequently tuberculosis (19%). Thirty-seven subjects (37%) were ARV-naive. Among those treated, 61 (97%) were on 3-drug combination potent ARV therapy with 94% on dNRTI-containing regimens. The ARV-experienced subgroup was slightly older (38 vs. 35 years, P = 0.04), and the median body mass index was slightly higher than in the ARV-naive subgroup (21 vs. 19.7, P = 0.04). The ARV-experienced subgroup, on average, had a higher CD4 count (217 vs. 44, P < 0.001), and among cases where data were available (22/63), 55% had undetectable plasma HIV RNA levels. Symptoms possibly suggestive of neuropathy were noted in 13 (35%) of 37 ARV-naive subjects and in 22 (35%) of 63 ARV-experienced subjects. Interestingly, neuropathic pain was a symptom found only in ARV-experienced subjects (7/63 ARV-experienced patients compared with 0/37 ARV-naive patients). Six (16%) of 37 ARV-naive subjects and 10 (16%) of 63 ARV-experienced subjects had 1 or more bilateral signs suggestive of neuropathy. Possible neuropathy criteria were met in 12 (32%) of 37 ARV-naive patients and in 16 (25%) of 63 ARV-experienced subjects for an overall rate of 28%. Only 10 subjects (10%) met the stringent study-defined criteria for probable HSN (Table 1). All were symptomatic. The rate of probable HSN did not differ between the ARV-naive (4/37 subjects, 10.6%) and ARV-experienced (6/63 subjects, 9.5%) subgroups. No differences in sex, age, or body mass index were noted between subjects with or without HSN in either the ARV-naive or ARV-experienced subgroups. A lower CD4 lymphocyte count was associated with higher risk of HSN in the cohort as a whole and specifically in the ARV-experienced subgroup with a similar trend in the ARV-naive subgroup. A trend toward lower HIV viral load as a risk factor for HSN was observed in the ARV-experienced cohort. We identified no difference in dNRTI exposure between those with and without HSN (P = 0.34); although 94% were on dNRTI-based treatment. TABLE 1 Demographic and HIV-Related Information Comparing Subjects With and Without Probable HSN for the Entire Cohort and Separately Among ARV-Naive and ARV-Experienced Subgroups In other reports, rates of HSN have varied widely, likely due to multiple factors including differences in HSN definitional criteria, variations in HIV stage, possible differences in host and viral clade parameters, and variation in rates, types, and duration of ARV treatments. Our protocol employed a strict definition determined by neurological evaluations conducted by neurologists and identifies an overall 10% frequency that does not differ by ARV status. The subjects were all Thai and were most likely infected with recombinant circulating form (CRF) 01_AE, the predominant HIV subtype found in Bangkok.10 The study is limited by the lack of statistical power due to its small sample size and by the incomplete immunovirologic information. However, it is interesting to note a lack of difference in probable HSN rates by ARV status. This finding is unexpected considering the high frequency of dNRTI use (94%), a factor expected to increase rates of antiretroviral toxic neuropathy. Although many studies have reported high rates of HSN up to 55% with dNRTI, other studies have reported a lower prevalence.4,11–13 Therefore, it is tempting to hypothesize that in our cohort, the tendency of dNRTI to induce neuropathy may have been outweighed by the favorable effects of immunologic benefit with potent ARV therapy, particularly because our cohort had severe immunosuppression. A careful prospective evaluation of HSN before and after use of both dideoxynucleoside-containing and nondideoxynucleoside-containing ARV regimens may be warranted. In terms of immunovirologic parameters, a trend for low CD4 count in association with HSN was found in the cohort as a whole and specifically among ARV-experienced subjects. This finding is similar to that reported in the HIV Outpatient Study and suggests that immunologic parameters continue to be important as a risk factor for HSN after use of potent ARV medications.14 The association of low HIV RNA levels with HSN in the ARV-experienced cohort may reflect better HIV medication adherence and increase exposure to the dideoxynucleoside medications; however, it is also notable that virological data were very limited. In summary, this study found an overall frequency of probable HSN at 10% and that of possible HSN at 28% among HIV-infected subjects attending an outpatient ID clinic in Bangkok, Thailand. Rates of HSN were comparable between ARV-naive and ARV-experienced subjects, despite the heavy use of dideoxynucleoside-containing medications in ARV-experienced subjects. Low CD4 count was a risk factor for HSN in general and specifically in ARV-experienced subjects. Further studies are warranted to prospectively evaluate the changes in rates of HSN after highly active antiretroviral therapy initiation with both dideoxynucleoside-containing and nondideoxynucleoside-containing regimens.

Patients with multifocal epilepsy are often considered unsuitable for epilepsy surgery. We report an adolescent with intractable frontal and occipital lobe seizures, secondary to complications of treatment for acute lymphoblastic leukaemia as a young child. Chemotherapy and radiotherapy were complicated by bilateral, posterior leukoencephalopathy and later an acquired frontal cerebral cavernous malformation (CCM). Detailed electro-clinical and imaging studies showed multiple, frontal lobe seizures per day with less frequent and non-debilitating, simple, occipital lobe seizures. Focal resection of the frontal CCM abolished the socially-disabling seizures with resultant marked improvement in the patient's quality of life at 12 months. Careful analysis of the type and impact of focal seizures in the setting of multifocal epilepsy may demonstrate that one seizure type is more deleterious to quality of life and may be amenable to surgery. In this situation, the patient may benefit significantly from surgery to resect the more active epileptic focus.

We compared cerebrospinal fluid (CSF) opening pressure measurements in the lumbar subarachnoid space between the flexed position (F-OP) and relaxed position (R-OP) in recumbent patients. We devised an equation for using F-OP to determine the existence of raised intracranial pressure (ICP). Patients (n = 83) underwent lumbar puncture while in the flexed lateral decubitus position and then were moved to the relaxed position. F-OP and R-OP were measured with a water manometer. R-OP > 180 mmH2O plus relevant clinical signs were taken as indicators of raised intracranial pressure. Mean pressures for F-OP and R-OP were 178.54 and 160.52 mmH2O respectively, p 180, raised ICP could be significantly over diagnosed. The authors recommend an equation [R-OP(calculated, mmH2O) = 0.885 × F-OP(measured, mmH2O)] or using 200 mmH2O as the threshold for increased ICP with flexed posture.

HIV Associated Dementia (HAD) is a complication of HIV infection in developed countries and is still poorly defined in resource-limited settings. In this study we investigated the expression of the monocyte phenotype CD14CD16HLADR and the inflammatory profiles in monocytes supernatants by surface-enhanced laser desorption/ionization-time of flight (SELDI-TOF) mass spectrometry in a cohort of HAD and non-HAD Thai volunteers prior to the initiation of ARV. The CD14CD16HLADR phenotype was significantly increased in monocytes from HAD and non-HAD versus negative controls, but there was no difference in phenotype and in the secretion protein profiles between the two seropositive groups. In addition, monocytes supernatants from HAD and non-HAD did not induced apoptosis or cell death in brain aggregate culture. In conclusion it appears that HAD in Thai individuals has a different immunological profile then in North America cohorts.

To determine the prevalence of depression among epileptic patients in Phramongkutklao Hospital and to find the factors associated with depression.One hundred and ten epileptic patients were enrolled and 60 patients met the inclusion criteria. These subjects were screened with Thai Geriatric Depressive Scale (TGDS) and were interviewed. Demographic data that effect depression were evaluated.During the 1-year study period, 60 of 110 patients diagnosed epilepsy were eligible. Prevalence of depression was 38.3%, which is similar to previous studies. Mild depression was found in 65.2% and moderate 34.8%, without severe depression. Comparing between male and female, there was no statistical significant difference (p = 0.75). The age group that compared between age equal or less than 25 years and more than 25 years had no statistical significant difference (p = 0.77). Other variables were not found to be significant risk factors of depression among epileptic patients including duration of seizures [equal or less than 5 and more than 5 per year (p = 0.43)], type of seizures [generalized tonic-clonic seizures and partial seizures (p = 0.69)], and number of antiepileptic drugs [monotherapy and polytherapy (p = 0.44)].Prevalence of depression among epileptic patients was 38.3%, divided between mild (65.2%) and moderate (34.8%). There were no significant risk factors correlated with depression. Epileptic patients should be made aware of this and seek prompt treatment for depression.