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million dollars in Treasury bonds is something just over a drop in the bucket What kind of effect would be applied to a single option strike price if 1,000 or 10,000 call options were offered at a certain price If the trader needed to get the trades done and was willing to allow some price discretion, somebody might notice and begin pulling bids to see how low the offers would go before arbitrage traders would pick them up Is there a chance that the option may trade at a discounted implied volatility Absolutely, especially in markets with less volume Conversely, if someone was buying the hedge, the option might trade at a premium or higher implied volatility When we talk about implied volatility, one of the items we are looking at is the skew of the implied across the available strike prices At times you will nd that out-of-the-money options have a higher implied volatility compared to the at-the-money or in-the-money options This is known as the volatility smile (see Figure 111)

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occur in the rst 48 h of febrile infection The only alternative way to establish the diagnosis of acute HSV encephalitis is by uorescent antibody study and by viral culture of cerebral tissue obtained by brain biopsy; the approach to biopsy as a diagnostic test varies among centers but its use has declined with the availability of the PCR test We nd it necessary to perform biopsy in only a minority of cases, preferring to treat the patient with antiviral agents based on compatible clinical, radiologic, and CSF ndings while we await serologic and PCR test results Treatment Until the late 1970s, there was no speci c treatment for HSV encephalitis A collaborative study sponsored by the National Institutes of Health and also a Swedish study indicated that the antiviral agent acyclovir signi cantly reduces both mortality and morbidity from the disease (Whitley et al; Skoldenberg et al) For this reason, it is our practice to initiate treatment while con rmatory testing is being carried out Acyclovir is given intravenously in a dosage of 30 mg/kg per day and continued for 10 to 14 days in order to prevent relapse Acyclovir carries little risk and can be discontinued if further clinical or laboratory features point to another diagnosis The main problems that arise from the drug are local irritation of the veins used for infusion, mild elevation of hepatic enzymes, or transient impairment of renal function Nausea, vomiting, tremor, or an encephalopathy that is dif cult to distinguish from the encephalitis itself occur in a very few patients The matter of relapse after treatment with acyclovir has been recognized increasingly, particularly in children Several potential mechanisms have been suggested by Tiege and colleagues, includ` ing an immune-mediated in ammatory response, but treatment with too low a dose or for too brief a period is undoubtedly the main cause of the rare relapses that occur in adults In children, a second course of acyclovir is usually successful When a large volume of brain tissue is involved, the hemorrhagic necrosis and surrounding edema act as an enlarging mass that requires separate attention Coma and pupillary changes should.

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Figure 33-1 Herpes simplex encephalitis Left: a T2-weighted coronal MRI in the axial plane, taken during the acute stage of the illness There is increased signal from practically all of the inferior and deep temporal lobe and the insular cortex Right: a T1-weighted image after gadolinium infusion showing enchancement of the left insular and temporal cortices and early involvement of the right temporal lobe

In the next illustration, you can see what happens to these objects when translated or mapped into the OLAP universe The dimension is Customer (technical name Z_BOBJ1) and


not be attributed to the mass effect unless compression of the upper brainstem is evident on brain imaging, since the infection is capable of spreading to the mesencephalon from the contiguous deep temporal lobe, thereby causing coma by a direct destructive effect All measures used in the management of brain edema due to mass lesions should be applied, but there are insuf cient data by which to judge their effectiveness The concern that corticosteroids may aggravate the infection has not been borne out by clinical experience, but a detrimental effect cannot be discounted Our experience (reported by Barnett et al) and that of Schwab and colleagues has been that the presence of raised intracranial pressure early in the illness presages a poor outcome Seizures are usually brought under control by high doses of conventional anticonvulsants The outcome of this disease, both the mortality and morbidity, is governed to a large extent by the patient s age and state of consciousness at the time of institution of acyclovir therapy If the patient is unconscious (except immediately after a convulsion), the outcome is uniformly poor However, if treatment is begun within 4 days of onset of the illness in an awake patient, survival is greater than 90 percent (Whitley) Evaluation of these patients 2 years after treatment showed 38 percent to be normal or nearly normal, whereas 53 percent were dead or severely impaired The neurologic sequelae are often of the most serious type, consisting of a Korsakoff amnesic defect or a global dementia, seizures, and aphasia (Drachman and Adams) If there were seizures during the acute illness, it is advisable to continue anticonvulsants for a year or more and then judge the advisability of discontinuing them on the basis of further seizures, the EEG, and the patient s exposure to situations that pose a danger, such as driving With the exception of the aforementioned rare relapsing cases, the infection does not recur.

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