Showing papers in "Dkgest of the World Latest Medical Information in 2005"

Preventing foot ulcers in patients with diabetes

Abstract: Context:Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4%to 10%, the annual population-based incidence is 1.0%to 4.1 %, and the lifetime incidence may be as high as 25%. These ulcers frequently b ecome infected, cause great morbidity, engender considerable financial costs, an d are the usual first step to lower extremity amputation. Objective:To systemat ically review the evidence on the efficacy of methods advocated for preventing d iabetic foot ulcers in the primary care setting. Data Sources, Study Selection, and Data Extraction:The EBSCO, MEDLINE, and the National Guideline Clearinghous e databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles wer e also searched, along with the Cochrane Library and relevant Web sites. We revi ewed the retrieved literature for pertinent information, paying particular atten tion to prospective cohort studies and randomized clinical trials. Data Synthesi s:Prevention of diabetic foot ulcers begins with screening for loss of protecti ve sensation, which is best accomplished in the primary care setting with a brie f history and the Semmes-Weinstein monofilament. Specialist clinics may quantif y neuropathy with biothesiometry, measure plantar foot pressure, and assess lowe r extremity vascular status with Doppler ultrasound and ankle-brachial blood pr essure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based o n risk and to determine the type of intervention. Educating patients about prope r foot care and periodic foot examinations are effective interventions to preven t ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of c alluses, and certain types of prophylactic foot surgery. The value of various ty pes of prescription footwear for ulcer prevention is not clear. Conclusions:Sub stantial evidence supports screening all patients with diabetes to identify thos e at risk for foot ulceration. These patients might benefit from certain prophyl actic interventions, including patient education, prescription footwear, intensi ve podiatric care, and evaluation for surgical interventions.

Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis

Abstract: BACKGROUND: Atherosclerotic intracranial arterial stenosis is an important cau se of stroke. Warfarin is commonly used in preference to aspirin for this disord er, but these therapies have not been compared in a randomized trial. METHODS: W e randomly assigned patients with transient ischemic attack or stroke caused by angiographically verified 50 to 99 percent stenosis of a major intracranial arte ry to receive warfarin (target international normalized ratio, 2.0 to 3.0) or as pirin (1300 mg per day) in a double-blind, multicenter clinical trial. The prim ary end point was ischemic stroke, brain hemorrhage, or death from vascular caus es other than stroke. RESULTS: After 569 patients had undergone randomization, e nrollment was stopped because of concerns about the safety of the patients who h ad been assigned to receive warfarin. During a mean follow-up period of 1.8 yea rs, adverse events in the two groups included death (4.3 percent in the aspirin group vs. 9.7 percent in the warfarin group; hazard ratio for aspirin relative t o warfarin, 0.46; 95 percent confidence interval, 0.23 to 0.90; P=0.02), major h emorrhage (3.2 percent vs. 8.3 percent, respectively; hazard ratio, 0.39; 95 per cent confidence interval, 0.18 to 0.84; P=0.01), and myocardial infarction or su dden death (2.9 percent vs. 7.3 percent, respectively; hazard ratio, 0.40; 95 pe rcent confidence interval, 0.18 to 0.91; P=0.02). The rate of death from vascula r causes was 3.2 percent in the aspirin group and 5.9 percent in the warfarin gr oup (P=0.16); the rate of death from nonvascular causes was 1.1 percent and 3.8 percent, respectively (P=0.05). The primary end point occurred in 22.1 percent o f the patients in the aspirin group and 21.8 percent of those in the warfarin gr oup (hazard ratio, 1.04; 95 percent confidence interval, 0.73 to 1.48; P=0.83). CONCLUSIONS: Warfarin was associated with significantly higher rates of adverse events and provided no benefit over aspirin in this trial. Aspirin should be use d in preference to warfarin for patients with intracranial arterial stenosis.

Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome

Abstract: BACKGROUND: Monochorionic twin pregnancies complicated by severe twin to twin transfusion syndrome at midgestation can be treated by either serial amnioreduction(removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments. METHODS: Pregnant women with severe twin to twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome),survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate. RESULTS:The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstrated a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of the survival of at least one twin to 28 days of age (76 percent vs. 56 percent; relative risk of the death of both fetuses, 0.63; 95 percent confidence interval, 0.25to 0.93; P=0.009) and 6 months of age (P=0.002). Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6 percent vs. 14 percent,P=0.02) and were more likely to be free of neurologic complications at six months of age (52 percent vs. 31 percent, P=0.003). CONCLUSIONS: Endoscopic laser coagulation of anastomoses is a more effective first linetreatment than serial amnioreduction for severe twin totwin transfusion syndrome diagnosed before 26 weeks of gestation.

Interferon beta-1b in secondary progressive MS: Results from a 3-year controlled study

Abstract: Objective: To evaluate the efficacy and safety of interferon beta- 1b (IFNβ - 1b) in subjects with secondary progressive multiple sclerosis (SPMS). Methods: This 3- year, multicenter, double- blind, placebo- controlled, randomized trial of IFNβ - 1b included 939 subjects from the United States and Canada with SPMS and Expanded Disability Status Scale (EDSS) scores ranging from 3.0 to 6.5. Subjects were randomly assigned to receive either placebo or IFNβ - 1b (250 μ g or 160 μ g/m2 body surface area), administered subcutaneously every other day. The primary outcome was time to progression by ≥ 1.0 EDSS point (0.5 point if EDSS score was 6.0 to 6.5 at entry)- confirmed at 6 months. Secondary outcomes included mean change in EDSS score from baseline, relapse- related measures, MRI activity, and a standardized neuropsychological function test. Results: There was no significant difference in time to confirmed progression of EDSS scores between placebo- treated patients and either of the IFNβ - 1b treatment groups. However, IFNβ - 1b treatment resulted in improvement on secondary outcome measures involving clinical relapses, newly active MRI lesions, and accumulated burden of disease on T2- weighted MRI. Effects were similar for both IFNβ - 1b treatment groups. Neutralizing antibodies to IFNβ - 1b were detected in 23% of 250- μ g and 32% of 160- μ g/m2 recipients, but their presence did not consistently affect clinical or MRI outcomes. IFNβ - 1b was also well tolerated at both doses. Conclusions: Although no treatment benefit was seen on the time to confirmed progression of disability, relapse- and MRI- related outcomes showed significant benefit with both dosing regimens tested, a result consistent with the outcomes of earlier clinical trials.

Causal relation between α synuclein gene duplication and familial Parkinson’s disease

Abstract: The α synuclein gene (SNCA) has been implicated in autosomal dominant forms of Parkinsons disease. We screened 119 individuals from families with this rar e form of the disease for SNCA duplications by semiquantitative multiplex PCR. T wo patients had duplications, which were confirmed by analysis of intragenic and flanking microsatellite markers. The phenotype in both patients was indistingui shable from idiopathic Parkinsons disease and no atypical features were presen t, by contrast with reports of families with triplication of the same gene. Thes e results indicate that SNCA is more frequently associated with familial Parkins ons disease than previously thought, and that there is a clear dosage effect a ccording to the number of supernumerary copies of this gene.

Incidence of parkinsonism and Parkinson disease in a general population: The Rot terdam Study

Abstract: Objective: To investigate the incidence of parkinsonism and Parkinson disease (PD) in the general population using inperson screening along with clinical data . Methods: In the Rotterdam study, a prospective population based cohort study of people aged ≥55 years, the authors assessed age and sex specific incidence r ates of parkinsonism and PD among 6,839 participants who were free of parkinsoni sm at baseline. Case finding involved in person screening at baseline and two f ollow up visits, and additional information was obtained through continuous mon itoring of the cohort by computer linkage to general practitionersand pharmacy records. Results: After a mean follow up period of 5.8 years, 132 subjects wit h incident parkinsonism were identified, of whom 67 (51%) had PD. The incidence of parkinsonism and PD increased with age, with incidence rates for PD increasi ng from 0.3 per 1000 person years in subjects aged 55 to 65 years, to 4.4 per 1 000 person years for those aged ≥85 years. The overall age adjusted incidence rate of any parkinsonism was not different in men and women, but men seem to ha ve a higher risk for PD (male to female ratio, 1.54; 95%CI, 0.95 to 2.51). Co nclusion: Incidence rates for parkinsonism and Parkinson disease were higher tha n those reported by most previous studies, possibly because of the authorsinte nsive case finding methods involving in person screening.

Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand

Abstract: BACKGROUND: Although zidovudine prophylaxis decreases the rate of trans mission of the human immunodeficiency virus (HIV) type 1 substantially, a large number of infants still become infected We hypothesized that the administration, in ad dition to zidovudine, of a single dose of oral nevirapine to mothers during labo r and to neonates would further reduce transmission of HIVMETHODS: We conducted a randomized, double-blind trial of three treatment regimens in Thai women who were receiving zidovudine therapy during the third trimester of pregnancy In o ne group, mothers and infants received a single dose of nevirapine (nevirapine- nevirapine regimen);in another, mothers and infants received nevirapineand place bo, respectively (nevirapine-placebo regimen); and in the last, mothers and inf ants received placebo (placebo-placebo regimen) The infants also received one week of zidovudine therapy and were formula-fedThe end point of the study was infection with HIV in the infants, established by virologic testing RESULTS:Bet ween January 15, 2001, and February 28, 2003, a total of 1844 Thai women were en rolled At the first interim analysis, the independent data monitoring committee stopped enrollment in the placebo-placebo groupAmong women who delivered befo re the interim analysis,the as-randomized Kaplan-Meier estimates of the transm ission rates were 11 percent (95 percent confidence interval, 03 to 22) in th e nevirapine-nevirapine group and 63 percent (95 percent confidence interval,3 8 to 89) in the placebo-placebo group (P 0001) The final per-protocol tra nsmission rate in the nevirapine-nevirapine group, 19 percent (95 percent conf idence interval,09 to 30), was not significantly inferior to the rate in the n evirapine-placebo group (28 percent; 95 percent confi-dence interval, 15 to 41) Nevirapine had an effect within subgroups defined by known risk factors su ch as viral load and CD4 count No serious adverse effects were associated with nevirapine therapy CONCLUSIONS: A single dose of nevirapine to the mother, with or without a dose of nevirapine to the infant, added to oral zidovudine prophyl axis starting at 28 weeks’gestation, is highly effective in reducing mother-to -child transmission of HIV

Immediate post-radiotherapy changes in malignant glioma can mimic tumor progression

Abstract: To determine the frequency of progressive MRI lesions shortly after radiotherapy for glioma with spontaneous improvement or stabilization, the authors studied a cohort of patients treated within two prospective phase III trials with radiotherapy only. In 9 out of 32 patients, the first post radiotherapy MRI showed progressive enhancement. In 3 of these 9 the MRI improved or stabilized for 6 months without additional treatment. The authors conclude that patients with progressive lesions within 3 months after radiotherapy should not be eligible for phase II trials on recurrent glioma.

Vestibular-evoked extraocular potentials produced by stimulation with bone-conducted sound

Abstract: Objective: To investigate the origin, whether ocular or extraocular, of the short latency frontal potential (N15) reported by Todd et al. (2003) following vestibular stimulation. Methods: Fourteen subjects with low VEMP thresholds (VT) and 9 patients with vestibular or ocular disorders were stimulated at the mastoid with bone-conducted tone bursts (500 Hz, 8 ms) above vestibular threshold, using a B71 bone vibrator. Surface potentials were recorded from Fpz and around the eyes and referred to linked earlobes. Results: The N15 was present at Fpz,but was largest around the eyes (mean amplitude 2.6 μV, peak latency 13.4 ms, with stimulation at +18 dB above threshold) and was generally in phase above and below the eyes. The response was vestibular-dependent and modulated by alteration of gaze direction. The potentials were delayed in a patient with Miller Fisher syndrome and were larger in patients with superior canal dehiscence than in controls. Conclusions: We report a new vestibular-evoked extraocular potential. Its properties are not consistent with an eye movement. It is likely to be produced, mainly or exclusively, by synchronous activity in extraocular muscles (i.e. a myogenic potential). Significance: Vestibularevoked extraocular potentials extend the range of vestibular pathways that can be assessed electrophysiologically, and may be a useful additional test of vestibular function.

The Preterm Prediction study:Association between maternal body mass index and spontaneous and indicated preterm birth

Abstract: Objective: The purpose of this study was to evaluate the relationship between prepregnancy maternal body mass index and spontaneous preterm birth and indicated preterm birth. Study design: This was a secondary analysis of the Maternal- Fetal Medicine Units Network, Preterm Prediction study. Patients were classified into categories that were based on their body mass index. Rates of indicated and spontaneous preterm birth were compared. Results: Five hundred ninety- seven (20.5% ) of 2910 women were obese. Obese women had fewer spontaneous preterm births at 37 weeks of gestation (6.2% vs 11.2% ; P . 001) and at 34 weeks of gestation (1.5% vs 3.5% ; P =. 012). Women with a body mass index of 19 kg/m2 had 16.6% spontaneous preterm birth, with a body mass index of 19 to 24.9 kg/m2 had 11.3% spontaneous preterm birth, with a body mass index of 25 to 29.9 kg/m2 had 8.1% spontaneous preterm birth, with a body mass index of 30 to 34.9 kg/m2 had 7.1% spontaneous preterm birth, and with a body mass index of ≥ 35 kg/m2 had 5.2% spontaneous eterm birth (P . 0001). Indicated delivery was responsible for an increasing proportion of preterm births with increasing body mass index (P =. 001). Obese women had lower rates of cervical length 25 mm (5% vs 8% pr.; P =. 012). Multivariable regression analysis confirmed a lower rate of spontaneous preterm birth in obese gravid women (odds ratio, 0.57; 95% CI, 0.39- 0.83; P =. 003). Conclusion: Obesity before pregnancy is associated with a lower rate of spontaneous preterm birth.

α-synuclein pathology does not predict extrapyramidal symptoms or dementia

Abstract: Intracytoplasmic aggregation of α  synuclein protein as Lewy bodies in the brainstem neurons is diagnostic for Parkinson s disease, whereas if this proc ess also occurs in the cortical neurons, it is considered pathognomonic for deme ntia with Lewy bodies However, the link between α synuclein incorporation into inclusions, neuronal dysfunction, and clinical symptoms needs to be clarified Another important issue of the pathogenetic puzzle is to understand where α  synuclein pathology begins and how it progresses in the brain To study this, we collected all cases from autopsy material (N = 904) that had α  synuclein pa thology in the dorsal motor nucleus of vagus,substantia nigra, and/or basal fore brain nuclei In this way, our study has a unique design because the selection o f material is entirely based on the presence of α  synuclein pathology regard less of clinical phenotype Retrospective clinical assessment then showed that o nly 32 (30% ) of 106 α  synuclein positive cases were diagnosed with a neu rodegenerative disorder The distribution or load of α  synuclein pathology d id not permit a dependable postmortem diagnosis of extrapyramidal symptoms or co gnitive impairment Some neurologically unimpaired cases had a reasonable burden of α  synuclein pathology in both brainstem and cortical areas, suggesting t hat α  synuclein positive structures are not definite markers of neuronal d ysfunction

Plasma adiponectin and insulin resistance in women with polycystic ovary syndrome

Abstract: Objective: To determine plasma adiponectin concentration in women with and without polycystic ovary syndrome (P- COS) and to assess possible correlations of adiponectin to the hormonal and metabolic parameters, including measures of insulin resistance (IR) Design: Case- control study Setting: Tertiary- referral university hospital Patient(s): One hundred eighty selected women were classified as follows: 45 obese (body mass index [BMI] 30 kg/m2) with PCOS; 45 lean (BMI 25 kg/m2) with PCOS; 45 obese (BMI 30 kg/m2) without PCOS, and 45 lean (BMI 25 kg/m2) without PCOS Intervention(s): Blood samples were collected from all women with or without PCOS between 8 and 11 am, after an overnight fast Main Outcome Measure(s): Serum levels of luteinizing hormone (LH), follicle- stimulating hormone (FSH), thyroidstimulatinghormone (TSH), free T4, testosterone (T), 17- α - hydro- xyprogesterone, 4- androstenedione (4- A), dehydroep- iandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), sex hormone- binding globulin (SHBG), insulin, and plasma levels of adiponectin and glucose Measures of IR included fasting serum insulin, glucose- to- insulin ratio, and homeostasis model assessment (HOMA) Result(s): Adiponectin concentrations were found to be significantly decreased in women with PCOS and in obese women without PCOS as compared with lean women without PCOS Adiponectin concentrations correlated inversely with body weight, BMI, fasting plasma glucose, serum insulin, 4- A, DHEA, DHEAS, and HOMA but correlated positively with serum T, SHBG, FAI, and glucose- to- insulin ratio Multiple regression analysis showed that BMI, HOMA, 4- A, and insulin were independent determinants of adiponectin concentrations Conclusion(s): Hypoadiponectinemia is evident in obese and lean women with PCOS with variable degree of IR; and it is suggested that IR per se or other metabolic abnormalities of PCOS are involved in the regulation of adiponectin concentration in women with PCOS

The pathological basis of semantic dementia

Abstract: Semantic dementia is a syndrome of progressive deterioration in semantic memory (knowledge of objects, people, concepts and words). It falls within the clinical spectrum of frontotemporal dementia but its pathology is yet to be studied systematically. This study included 18 consecutive post mortem cases meeting clinical criteria for semantic dementia. Clinic records and diagnostic histopathology were available for all cases; structural neuroimaging, neuropsychology and semi-quantitative histo-pathology/immunohistochemistry data were analysed where possible. The pathological diagnosis in a clear majority of cases was frontotemporal degeneration with ubiquitin inclusions (n = 13). Eleven of these cases had characteristic motor neuron disease-type inclusions in the dentate gyrus and cerebral cortex. Ubiquitin inclusions were found only in the inferior olivary nucleus in the other two, one of which was the only case to show degeneration of motor tracts and also to have shown evidence of motor neuron disease during life. None of the patients had motor symptoms or signs at presentation. A family history of motor neuron disease was documented in one case. Pick bodypositive Pick's disease appeared three times. Two cases had Alzheimer's disease and significant coincidental Alzheimertype pathology was also found in one of the ubiquitin inclusion cases. One of the Alzheimer's disease patients had changes in white matter signal on scanning, whereas all other scans showed cerebral atrophy only. Semi-quantitative assessment of regional neuronal loss found that anterior and inferior temporal regions bore the brunt of disease across all histopathological subtypes, usually on the left side, implicating this region in semantic processing.

Lymphvascular space involvement:An independent prognostic factor in endometrial cancer

Abstract: Purpose of investigation To evaluate whether lymphvascular space involvement (LVSI) is a risk factor for relapse of disease and lymph node metastasis in endometrial cancer Methods From 1978 till 2003, 609 patients with epithelial endometrial cancer were treated at the Groningen University Medical Center The association of LVSI and relapse of disease was evaluated in the total group of 609 patients and in a ‘ low' and ‘ high' risk stage I endometrial cancer group In 239 surgically staged patients, the relation of LVSI and lymph node metastasis was investigated Results The median age at diagnosis was 63 years (range 27- 92 years) with a median follow- up of 58 months (range 0- 236 months) More than half of the patients (56% ) received adjuvant radiotherapy LVSI was present in 123 patients (25,6% ), and a prognostic factor for relapse of disease (multivariate analysis, P 00001) In the ‘ low' and ‘ high' risk stage I endometrial cancer patients an increase of 26 times in relapse of disease was observed in the presence of LVSI LVSI positive tumors were more likely to have metastasized to the pelvic lymph nodes (multivariate analysis, P = 0001) In patients with proven negative nodes, LVSI was a prognostic factor for relapse of disease (univariate analysis, P = 002) Conclusion LVSI is a predictor of nodal disease and an independent prognostic factor for relapse of disease in all stages of endometrial cancer Patients with stage I endometrial cancer with positive LVSI are at risk for relapse of disease and might therefore benefit from adjuvant therapy Content The presence of lymphvascular space involvement (LVSI) in endometrial cancer is significantly and independently associated with an increased risk of pelvic lymph node metastases and/or relapse of disease

Clinical features and prognostic factors in adults with bacterial meningitis

Abstract: BACKGROUND: We conducted a nationwide study in the Netherlands to determine cl inical features and prognostic factors in adults with community acquired acute bacterial meningitis. METHODS: From October 1998 to April 2002, all Dutch patien ts with community acquired acute bacterial meningitis, confirmed by cerebrospin al fluid cultures, were prospectively evaluated. All patients underwent a neurol ogic examination on admission and at discharge, and outcomes were classified as unfavorable (defined by a Glasgow Outcome Scale score of 1 to 4 points at discha rge) or favorable (a score of 5). Predictors of an unfavorable outcome were iden tified through logis tic regression analysis. RESULTS: We evaluated 696 episod es of community acquired acute bacterial meningitis. The most common pathogens were Streptococcus pneumoniae (51 percent of pisodes) and Neisseria meningitidis (37 percent). The classic triad of fever, neck stiffness, and a change in menta l status was present in only 44 percent of episodes; however, 95 percent had at least two of the four symptoms of headache, fever, neck stiffness, and altered m ental status. On admission, 14 percent of patients were comatose and 33 percent had focal neurologic abnormalities. The overall mortality rate was 21 percent. T he mortality rate was higher among patients with pneumococcal meningitis than am ong those with meningococcal meningitis (30 percent vs. 7 percent, P 0.001). Th e outcome was unfavorable in 34 percent of episodes. Risk factors for an unfavor able outcome were advanced age, presence of otitis or sinusitis, absence of rash, a low score on the Glasgow Coma Scale on admission , tachycardia, a positive blood culture, an elevated erythrocyte sedimentation r ate, thrombocytopenia, and a low cerebrospinal fluid white cell count. In adult s presenting with community acquired acute bacterial meningitis, the sensitivit y of the classic triad of fever, neck stiffness, and altered mental status is lo w, but almost all present with at least two of the four symptoms of headache, fe ver, neck stiffness, and altered mental status. The mortality associated with ba cterial meningitis remains high, and the strongest risk factors for an unfavorab le outcome are those that are indicative of systemic compromise, a low level of consciousness, and infection with S. pneumoniae.

Does anticipation of back pain predispose to back trouble

Abstract: Limb movement imparts a perturbation to the body The impact of that perturbat ion is limited via anticipatory postural adjustments The strategy by which the CNS controls anticipatory postural adjustments of the trunk muscles during limb movement is altered during acute back pain and in people with recurrent back pai n, even when they are pain free The altered postural strategy probably serves t o protect the spine in the short term, but it is associated with a cost and is t hought to predispose spinal structures to injury in the long term It is not kno wn why this protective strategy might occur even when people are pain free, but one possibility is that it is caused by the anticipation of back pain In eight healthy subjects, recordings of intramuscular EMG were made from the trunk muscl es during single and repetitive arm movements Anticipation of experimental back pain and anticipation of experimental elbow pain were elicited by the threat of painful cutaneous stimulation There was no effect of anticipated experimental elbow pain on postural adjustments During anticipated experimental back pain, f or single arm movements there was delayed activation of the deep trunk muscles a nd augmentation of at least one superficial trunk muscle For repetitive arm mov ements, there was decreased activity and a shift from biphasic to monophasic act ivation of the deep trunk muscles and increased activity of superficial trunk mu scles during anticipation of back pain In both instances, the changes were cons istent with adoption of an altered strategy for postural control and were simila r to those observed in patients with recurrent back pain We conclude that antic ipation of experimental back pain evokes a protective postural strategy that sti ffens the spine This protective strategy is associated with compressive cost an d is thought to predispose to spinal injury if maintained long term

Early-stage diffuse unilateral subacute neuroretinitis:Improvement of vision after photocoagulation of the worm

Abstract: Purpose:To evaluate the visual outc ome after direct laser photocoagulation of the worm in patients with early-stage diffuse unilateral subacute neuroretinitis(DUSN).Meth-ods:We report on four patients with D USN diagnosed in its early stage,in whom the worm was i dentified and de-stroyed by laser photocoagulation.Results:In all the four cases,resolution of the inflammato ry multifocal lesions was achieved within 1month of treatment .After that period and during follow-up(mean 11.5months),visual acuity im-proved in three eyes and remained unchanged in one eye.Conclusion:The diagnosis of DUSN in its early stage fol-lowed by prompt location and destruction of the worm by photocoagulation may improve visio n of affected patients.

Ultrasonography shows extensive nerve enlargements in multifocal motor neuropathy

Abstract: Using ultrasonography we found multiple sites with nerve enlargement along the course of the brachial plexus, median, ulnar, and radial nerves in the majority of 21 patients with multifocal motor neuropathy. Sonography and electrophysiologic studies showed more abnormalities than expected on purely clinical grounds. Moreover, sonography revealed nerve enlargement without clinical or electrophysiologic abnormalities.

Pathologically proven frontotemporal dementia presenting with severe amnesia

Abstract: Early and severe memory impairment is generally held to be an exclusion criter ion for the clinical diagnosis of frontotemporal dementia (FTD). However, clinic al experience suggests that some patients with otherwise typical FTD can be amne sic from presentation, or even present solely with amnesia. A review of severe a mnesia at presentation in patients with pathologically proven FTD is therefore w arranted. The present study examined the records of all patients in the joint Ca mbridge-Sydney neuropathological series of patients with dementia and a patholo gical diagnosis of FTD to identify those for whom memory complaints were dominan t at presentation. Eight of 71 patients met these criteria. For two patients, me mory loss was the only complaint; for one patient, memory loss was accompanied b y personality change; for two patients, memory loss was accompanied by prominent dysexecutive symptoms; and for three patients, memory loss was accompanied by a pathy but no other behavioural changes. In seven patients local specialist teams initially diagnosed Alzheimer's disease; four patients entered anticholinester ase drug trials. All eight later developed behavioural features: in four, the di agnosis was revised to FTD, while in four the diagnosis of FTD was made only on europathological examination after death. In conclusion, severe amnesia at prese ntation in FTD is commoner than previously thought and the clinical consensus cr iteria for the diagnosis of FTD may need to be revised. The underlying basis of the memory impairments in patients with FTD may be heterogeneous, with different explanations in different subgroups.

Pergolide use in Parkinson disease is associated with cardiac valve regurgitation

Abstract: Objective: To determine if pergolide injures heart valves, by comparing echocardiographic findings in pergolide treated patients with those of a historical control group Methods: Letters were sent to all patients in the authors’ practice believed to be taking pergolide, and those responders who wished to continue it were urged to undergo echocardiography Echocardiograms were obtained on 46 patients, and scores for valvular regurgitation were compared with those from an age matched control group derived from the Framingham Study The composite valve regurgitation score was modeled as a linear function of total milligrams lifetime use of pergolide, controlling for age Results: Eightynine percent of pergolide treated patients had some degree of valvular insufficiency For each of the three valves for which there are control data, we found an approximately 2 to 3 fold increased risk of abnormal valves in the pergolide patients (odds ratio ≈ 3) and an estimated 14 fold increased risk of concerning tricuspid regurgitation (OR = 184) The composite valve score (the sum of valve scores for each of the four valves) was a function of lifetime pergolide use Conclusion: Pergolide may injure cardiac valves, resulting most commonly in tricuspid regurgitation

Pelvic organ prolapse in older women: Prevalence and risk factors

Abstract: OBJECTIVE: We sought to estimate the prevalence of pelvic organ prolapse in ol der women using the Pelvic Organ Prolapse Quantification examination and to iden tify factors associated with prolapse. METHODS: Women with a uterus enrolled at one site of the Women's Health Initiative Hormone Replacement Therapy randomize d clinical trial were eligible for this ancillary cross-sectional study. Subjec ts underwent a Pelvic Organ Prolapse Quantification examination during a maximal Valsalva maneuver and in addition completed a questionnaire. Logistic regressio n was used to identify independent risk factors for each of 2 definitions of pro lapse: 1) Pelvic Organ Prolapse Quantification stage II or greater and 2) the le ading edge of prolapse measured at the hymen or below. RESULTS: In 270 participa nts, age (mean ±.SD) was 68.3 ±.5.6 years, body mass index was 30.4 ±6.2 kg/m 2, and vaginal parity (median [range]) was 3 (0-12). The proportions of Pelvic Organ Prolapse Quantification stages (95%confidence intervals [CIs]) were stage 0, 2.3%(95%CI 0.8-4.8%); stage I, 33.0%(95%CI 27.4-39.0%); stage II, 62 .9%(95%CI 56.8-68.7%); and stage III, 1.9%(95%CI 0.6-4.3%). In 25.2%(95 %CI 20.1-30.8%), the leading edge of prolapse was at the hymen or below. Horm one therapy was not associated with prolapse (P = .9). On multivariable analysis , less education (odds ratio [OR]-2.16, 95%CI 1.10-4.24) and higher vaginal p arity (OR 1.61, 95%CI 1.03-2.50) were associated with prolapse when defined as stage II or greater. For prolapse defined by the leading edge at or below the h ymen, older age had a decreased risk (OR 0.50, 95%CI 0.27-0.92) and less educa tion, and larger babies had an increased risk (OR 2.38, 95%CI 1.31-4.32 and OR 1.97, 95%CI 1.07-3.64, respectively). CONCLUSION: Some degree of prolapse is nearly ubiquitous in older women, which should be considered in the development of clinically relevant definitions of prolapse. Risk factors for prolapse differ ed depending on the definition of prolapse used.

Relation between reduction of foveal thickness and visual acuity in diabetic macular edema treated with intravitreal triamcinolone

Abstract: PURPOSE: To evaluate the correlation between improvement in visual acuity and the reduction of foveal thickness after a single intravitreal injection of 4 mg of triamcinolone in diabetic macular edema. DESIGN: Prospective, interventional, nonrandomized clinical trial. METHOD: PATIENTS: In a prospective study 24 eyes with diabetic macular edema were treated with an intravitreal injection of 4 mg of triamcinolone acetonide. MAIN OUTCOME MEASURES: Best-corrected logMAR visual acuity and optical coherence tomography were performed at baseline and 3 months after the treatment. RESULTS: At baseline the average foveal thickness was 462±154 μm(95%confidence interval, 397-527μm) and at 3 months 257 ±114 μm (95%confidence interval, 209-305 μm) (P .0001). The best-corrected logMAR average visual acuity was 60.5±10.5 (95%confidence interval, 56.0-65.0) ETDRS letters at baseline compared with 65.5±11.1 (95%confidence interval, 60.8-70.1) 3 months after the injection (P=.0001). There was no correlation between the improvement in visual acuity and the reduction of foveal thickness (r=0.054, P=.8), but there was a correlation between reduction in foveal thickness and the age of the patients (r=0.53, P=.008). CONCLUSION: A single injection of 4 mg of intravitreal triamcinolone acetonide effectively reduces the foveal thickness in diabetic macular edema and improves visual acuity, but there does not appear to be a strong correlation between the reduction of foveal thickness and the improvement in visual acuity.

Vitrectomy and gas tamponade without internal limiting membrane peeling for myopic foveoschisis

Abstract: Aim: To evaluate the clinical and anatomical outcomes of pars plana vitrectomy and gas tamponade without internal limiting membrane (ILM) peeling in symptomatic patients caused by myopic foveoschisis. Methods: Nine eyes in eight highly myopic patients who had myopic foveoschisis with foveal detachment underwent vitrectomy without ILM peeling followed by gas tamponade. Main outcome measures include change in best corrected visual acuity (BCVA) and changes in height of the foveal detachment and resolution of the myopic foveoschisis measured by optical coherence tomography (OCT). Results: After surgery, BCVA improved in eight eyes with the median BCVA improved from 20/80 to 20/50 (p=0.012). The mean line of visual improvement was 3.6 lines. OCT showed complete resolution of myopic foveoschisis with complete foveal reattachment in seven (77.8% ) eyes with partial resolution in two (22.2% ) eyes. The mean height of foveal detachment decreased from 505 μ m preoperatively to 21 μ m postoperatively (p 0.001). Conclusions: Vitrectomy without ILM peeling followed by gas tamponade appeared to result in favourable visual and anatomical outcomes for treating myopic foveoschisis in highly myopic eyes. The results are comparable with studies in which ILM removal was performed. Further controlled study will be useful to determine the role of ILM peeling in these patients.

Hyperglycemia, blood pressure, and the 9-year incidence of diabetic retinopathy: The Barbados Eye Studies

Abstract: Objectives: To evaluate factors related to the incidence of diabetic retinopathy (DR) in a population of African descent, after 9 years of follow-up. Design: Population-based cohort study; 81%participation after 9 years. Participants: Three hundred twenty-four participants of the Barbados Eye Studies, with diabetes mellitus (DM) at baseline and at risk for developing DR during follow-up. Methods: Diabetes-related changes were assessed by masked gradings of baseline and follow-up photographs using a standardized system. The 9-year cumulative incidence of DR was based on participants with DM and free of retinopathy at baseline; incidence rates were estimated by the product-limit approach. Cox regression models for discretetime data were used to evaluate risk factors associated with the 9-year incidence of DR. Results: Multivariate analyses revealed that older age at DM onset decreased the 9-year risk of DR development; for each 10 years of older age at onset, the risk of DR decreased by 30%(risk ratio [RR], 0.7; 95%confidence interval [CI], 0.56-0.96). The risk of DR doubled among persons with DM duration between 5 and 9 years (RR, 2.1; 95%CI, 1.2-3.6) versus those with shorter durations; it also doubled in those treated with oral medications or insulin at baseline versus those treated with diet only. Antihypertensive treatment halved the risk of DR versus no treatment (RR, 0.5; 95%CI, 0.3-0.9) and high systolic or diastolic blood pressure (BP) increased risk. Thus, DR risk increased by 30%for every 10 mmHg of higher systolic BPat baseline (RR, 1.3; 95%CI, 1.1-1.4) or of BPincrease from baseline to the 4-year follow-up (RR, 1.3; 95%CI, 1.1-1.4). Diabetic retinopathy risk similarly increased with each 1%of higher glycosylated hemoglobin level at baseline (RR, 1.3; 95%CI, 1.2-1.5). Conclusions: The long-term follow-up of persons with DM in this population of African origin, where disease prevalence is high, identified important potentially modifiable risk factors for DR. Findings suggest that efforts to achieve optimal glycemic and BPcontrol may reduce the vision-threatening complications of DM.

Cortical reorganization in malformations of cortical development: A magnetoencephalographic study

Abstract: Background: The evaluation for epilepsy surgery of patients with malformations of cortical development (MCDs) in areas of clinically important cerebral function is a challenge because of the unpredictable localization of critical sensory, motor, and cognitive function. Magnetoencephalography (MEG) source localization of evoked fields can address whether functional reorganization of primary sensory modalities exists in MCDs. Methods: Consecutive patients with MRI- demonstrated rolandic and calcarine cortex MCDs were identified who had a 148- channel whole- head MEG study to identify the localization of primary somatosensory and visual cortices. Reorganization was considered when localization contrasted that expected upon general anatomic or homuncular rules and was defined against controls. Results: Twelve patients (n = 12) were studied. Six had focal cortical dysplasia, two had polymicrogyria and schizencephaly, and four had isolated polymicrogyria. In the patients with cortical dysplasias, the somatosensory cortices were identified outside the rolandic area. In the two patients with polymicrogyria and schizencephaly, the somatosensory cortices remained in the rolandic areas as long as the anatomy was not distorted by the presence of the schizencephalic cleft. In the patients with isolated polymicrogyria, the somatosensory cortex was mapped without evidence of reorganization. Conclusion: In patients with epileptic MCDs involving rolandic and calcarine regions, cortical function may be reorganized if the MCDs are due to an abnormal neuronal or glial proliferation (i.e., cortical dysplasia) but may not be in MCDs caused by abnormal cortical organization (i.e., polymicrogyria).

Hyperhomocysteinemia, pregnancy complications, and the timing of investigation

Abstract: OBJECTIVE: To assess associations between vitamin-dependent homocysteine me ta bolism and vascular-related pregnancy complications by considering interval bet ween delivery and postpartam investigation and maternal age. METHODS: Casecontro l study performed at the University Medical Center Nijmegen in the Netherlands. Patients had experienced pregnancy-induced hypertension (n = 37), preeclampsia (n = 144), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (n = 104), recurrent early pregnancy loss (n = 544), abruptio placentae (n = 135), intrauterine growth restriction (n = 144), or intrauterine fetal death (n = 104) . Controls comprised 176 women with uncomplicated obstetric histories. Oral meth ionine loading tests and fasting vitamin profiles were performed more than 6 wee ks after delivery. Odds ratios and 95%confidence intervals were calculated afte r logistic regression analysis. RESULTS: Hyperhomocysteinemia was associated wit h an approximately 2-fold to 3-fold increased risk for pregnancy-induced hype rtension, abruptio placentae, and intrauterine growth restriction. Cobalamin def iciency was associated with HELLP syndrome, abruptio placentae, intrauterine gro wth restriction, and intrauterine fetal death. Pyridoxal 5phosphate deficiency i ncreased the risk for pregnancy-induced hypertension 4-fold. These association s lost their significance after adjustment for time interval and maternal age. H igh red cell folate was associated with a decreased risk for abruptio placentae and intrauterine growth restriction. An increased creatinine concentration was a ssociated with pregnancy-induced hypertension, preeclampsia, HELLP syndrome, an d abruptio placentae. CONCLUSION: Hyperhomocysteinemia and vitamin deficiencies are largely determined by the interval between delivery and postpartum investiga tion and by maternal age. Time interval and maternal age should be considered in the risk estimation for vascular-related pregnancy complications.

Photoreceptor layer features in eyes with closed macular holes: Optical coherence tomography findings and correlation with visual outcomes

Abstract: Purpose: Study correlation between optical coherence tomography (OCT) findings and visual acuity (VA) outcomes after successful macular hole surgery (MHS).Design: Retrospective cross- sectional study. Methods: PostoperativeOCT scans were analyzed in 34 eyes of 30 patients. Raw files of horizontal and vertical OCT scans were exported to Adobe Photoshop 7.0. Measured parameters included central foveal thickness, photoreceptor thickness, photoreceptor reflectivity, and relative reflectivity of photoreceptor to retinal pigment epithelium in the foveal area. Foveal configuration was subjectively graded. Results: OCT scans were obtained at a median of 2 years (1 month to 10 years) postoperatively. The median visual acuity was 20/80 (20/50 to 8/200) preoperatively and 20/50 (20/20 to5/200) postoperatively. The median foveal thickness was 198.5 μ (148 to 283). The mean (SD) photoreceptor layer thickness was 16.5 (8) μ in the 500 μ area and 17.5 (8) μ in the 1000 μ area. Mean (SD) of relative reflectivity of the photoreceptor layer was 0.60 (0.10) in both 500 μ and 1000 μ area. Postoperative VA did not correlate with foveal thickness or foveal configuration. Central (500 μ and 1000 μ ) photoreceptor thicknesswas significantly correlated with final VA(r=.38, P=.026, each). Relative reflectivity of photoreceptors to retinal pigment epithelium in the 500 μ area was correlated with postoperative VA at a borderline significance (r=.32, P=.07). Relative reflectivity of photoreceptors to retinal pigment epithelium in the 1000 μ area was not significantly correlated with postoperative VA (r=.27, P=.12). Conclusion: Specific retinal features can be assessed from OCT images. Morphology and thickness of the foveal photoreceptor layer correlate well with macular function after successful MHS. Outer retinal features appear to be more important to determine postoperative visual function. Inner retinal features may be more relevant for the ophthalmoscopic appearance of anatomic closure.

Unilateral pallidotomy versus bilateral subthalamic nucleus stimulation in PD: A comparison of neuropsychological effects

Abstract: Objective: To compare the cognitive and behavioural effects of unilateral pall idotomy and bilateral subthalamic nucleus (STN)stimulation. Methods: After basel ine examination 34 patients were randomly assigned to unilateral pallidotomy (4 left-sided,10 right-sided) or bilateral STN stimulation (n=20). At baseline an d six and twelve months after surgery we administered neuropsychological tests o f language, memory, visuospatial function, mental speed and executive functions. Also a depression rating scale, and self and proxy ratings of memory and dysexe cutive symptoms were administered. Results: Six months after surgery, the STN gr oup and the pallidotomy group differed significantly in change from baseline in number of errors on two tests of executive functioning. After 12 months the STN group reported less positive affect compared with baseline than the pallidotomy group. One patient in the STN group showed an overall cognitive deterioration du e to complications.Conclusions: Although we need larger groups to draw firm conc lusions, our results suggest that bilateral STN stimulation has slightly more ne gative effects on executive functioning than unilateral pallidotomy.

Neurologic features of horizontal gaze palsy and progressive scoliosis with mutations in ROBO3

Abstract: Objective: To review the neurologic, neuroradiologic, and electrophysiologic features of autosomal recessive horizontal gaze palsy and progressive scoliosis (HGPPS), a syndrome caused by mutation of the ROBO3 gene on chromosome 11 and associated with defective decussation of certain brainstem neuronal systems. Methods: The authors examined 11 individuals with HGPPS from five genotyped families with HGPPS. Eight individuals had brain MRI, and six had electrophysiologic studies. Results: Horizontal gaze palsy was fully penetrant, present at birth, and total or almost total in all affected individuals. Convergence, ocular alignment, congenital nystagmus, and vertical smooth pursuit defects were variable between individuals. All patients developed progressive scoliosis during early childhood. All appropriately studied patients had hypoplasia of the pons and cerebellar peduncles with both anterior and posterior midline clefts of the pons and medulla and electrophysiologic evidence of ipsilateral corticospinal and dorsal column-medial lemniscus tract innervation. Heterozygotes were unaffected. Conclusions: The major clinical characteristics of horizontal gaze palsy and progressive scoliosiswere congenital horizontal gaze palsy and progressive scoliosis with some variability in both ocular motility and degree of scoliosis. The syndrome also includes a distinctive brainstem malformation and defective crossing of some brainstem neuronal pathways.

Obstetric outcome of patients with polycystic ovary syndrome treated by in vitro maturation and in vitro fertilization-embryo transfer

Abstract: Objective: To assess the obstetric outcome of pregnancies resulting from in vi tro maturation (IVM) and IVF-ET of immature oocytes retrieved from women with p olycystic ovary syndrome (PCOS) Design: Prospective observational study Settin g: University fertility clinic Patient(s): One hundred thirty-nine women under going 203 IVM treatment cycles Intervention(s): Immature oocyte recovery from u nstimulated ovaries In vitro oocyte maturation and fertilization Fresh ET and assessment of obstetric outcomes in the pregnant women Main Outcome Measure(s): Pregnancy and obstetric outcome Result(s): Forty-one pregnancies were obtaine d in 187 ETs, resulting in a pregnancy rate of 219% Except for three patients lost to follow-up in these pregnancies, the abortion and live birth rates were 368%(14 of 38) and 632%(24 of 38), respectively The mean (±SD) gestationa l age and birth weight at delivery for singletons were 384 ±20 weeks (range, 33-416 weeks) and 3,252 ±516 g (1,750-4,100 g), respectively For twins the se were 367 ±19 weeks (346-39 weeks) and 2,361 ±304 g (1,900-2,990 g), r espectively Pregnancy complications occurred in five patients (132%); these i ncluded preterm labor (n = 3) and placenta previa (n = 2) Two patients (53%) had a major congenital anomaly diagnosed by ultrasonography Conclusion(s): The abortion rate, gestational age and birth weight at delivery, and obstetric compl ications of pregnancies conceived by IVM-ET in women with PCOS were comparable with those of other women with PCOS being treated by conventional IVF-ET In vi tro maturation followed by IVF-ET seems to be a useful treatment option for wom en with PCOS, thus avoiding the risk of ovarian hyperstimulation syndrome