Comparison of symptomatic and asymptomatic atherosclerotic carotid plaques using parallel imaging and 3 T black-blood in vivo CMR

BACKGROUND

To determine if black-blood 3 T cardiovascular magnetic resonance (bb-CMR) can depict differences between symptomatic and asymptomatic carotid atherosclerotic plaques in acute ischemic stroke patients.

METHODS

In this prospective monocentric observational study 34 patients (24 males; 70 ±9.3 years) with symptomatic carotid disease defined as ischemic brain lesions in one internal carotid artery territory on diffusion weighted images underwent a carotid bb-CMR at 3 T with fat-saturated pre- and post-contrast T1w-, PDw-, T2w- and TOF images using surface coils and Parallel Imaging techniques (PAT factor = 2) within 10 days after symptom onset. All patients underwent extensive clinical workup (lab, brain MR, duplex sonography, 24-hour ECG, transesophageal echocardiography) to exclude other causes of ischemic stroke. Prevalence of American Heart Association lesion type VI (AHA-LT6), status of the fibrous cap, presence of hemorrhage/thrombus and area measurements of calcification, necrotic core and hemorrhage were determined in both carotid arteries in consensus by two reviewers who were blinded to clinical information. McNemar and Wilcoxon's signed rank tests were use for statistical comparison. A p-value <0.05 was considered statistically significant.

RESULTS

Symptomatic plaques showed a higher prevalence of AHA-LT6 (67.7% vs. 11.8%; p < 0.001; odds ratio = 12.5), ruptured fibrous caps (44.1% vs. 2.9%; p < 0.001; odds ratio = 15.0), juxtaluminal thrombus (26.5 vs. 0%; p < 0.01; odds ratio = 7.3) and intraplaque hemorrhage (58.6% vs. 11.8%; p = 0.01; odds ratio = 3.8). Necrotic core and hemorrhage areas were greater in symptomatic plaques (14.1 mm2 vs. 5.5 mm2 and 13.6 mm2 vs. 5.3 mm2; p < 0.01, respectively).

CONCLUSION

3 T bb-CMR is able to differentiate between symptomatic and asymptomatic carotid plaques, demonstrating the potential of bb-CMR to differentiate between stable and vulnerable lesions and ultimately to identify patients with low versus high risk for cardiovascular complications. Best predictors of the symptomatic side were a ruptured fibrous cap, AHA-LT 6, juxtaluminal hemorrhage/thrombus, and intraplaque hemorrhage.

Parietal cortex codes for egocentric space beyond the field of view

Our subjective experience links covert visual and egocentric spatial attention seamlessly. However, the latter can extend beyond the visual field, covering all directions relative to our body. In contrast to visual representations, little is known about unseen egocentric representations in the healthy brain. Parietal cortex appears to be involved in both, because lesions in it can lead to deficits in visual attention, but also to a disorder of egocentric spatial awareness, known as hemispatial neglect. Here, we used a novel virtual reality paradigm to probe our participants' egocentric surrounding during fMRI recordings. We found that egocentric unseen space was represented by patterns of voxel activity in parietal cortex, independent of visual information. Intriguingly, the best decoding performances corresponded to brain areas associated with visual covert attention and reaching, as well as to lesion sites associated with spatial neglect.

Characteristics of carotid atherosclerotic plaques of chronic lipid apheresis patients as assessed by in vivo high-resolution CMR--a comparative analysis

BACKGROUND

Components of carotid atherosclerotic plaques can reliably be identified and quantified using high resolution in vivo 3-Tesla CMR. It is suspected that lipid apheresis therapy in addition to lowering serum lipid levels also has an influence on development and progression of atherosclerotic plaques. The purpose of this study was to evaluate the influence of chronic lipid apheresis (LA) on the composition of atherosclerotic carotid plaques.

METHODS

32 arteries of 16 patients during chronic LA-therapy with carotid plaques and stenosis of 1-80% were matched according to degree of stenosis with 32 patients, who had recently suffered an ischemic stroke. Of these patients only the asymptomatic carotid artery was analyzed. All patients underwent black-blood 3 T CMR of the carotids using parallel imaging and dedicated surface coils. Cardiovascular risk factors were recorded. Morphology and composition of carotid plaques were evaluated. For statistical evaluation Fisher's Exact and unpaired t-test were used. A p-value <0.05 was considered statistically significant.

RESULTS

Patients in the LA-group were younger (63.5 vs. 73.9. years, p<0.05), had a higher prevalence of hypercholesterolemia and of established coronary heart disease in patients and in first-degree relatives (p<0.05, respectively). LA-patients had smaller maximum wall areas (49.7 vs. 59.6mm2, p<0.05), showed lower prevalence of lipid cores (28.1% vs. 56.3%, p<0.05) and the lipid content was smaller than in the control group (5.0 vs. 11.6%, p<0.05). Minimum lumen areas and maximum total vessel areas did not differ significantly between both groups.

CONCLUSION

Results of this study suggest that, despite a severer risk profile for cardiovascular complications in LA-patients, chronic LA is associated with significantly lower lipid content in carotid plaques compared to plaques of patients without LA with similar degrees of stenosis, which is characteristic of clinically stable plaques.

Coding of melodic gestalt in human auditory cortex

The perception of a melody is invariant to the absolute properties of its constituting notes, but depends on the relation between them-the melody's relative pitch profile. In fact, a melody's "Gestalt" is recognized regardless of the instrument or key used to play it. Pitch processing in general is assumed to occur at the level of the auditory cortex. However, it is unknown whether early auditory regions are able to encode pitch sequences integrated over time (i.e., melodies) and whether the resulting representations are invariant to specific keys. Here, we presented participants different melodies composed of the same 4 harmonic pitches during functional magnetic resonance imaging recordings. Additionally, we played the same melodies transposed in different keys and on different instruments. We found that melodies were invariantly represented by their blood oxygen level-dependent activation patterns in primary and secondary auditory cortices across instruments, and also across keys. Our findings extend common hierarchical models of auditory processing by showing that melodies are encoded independent of absolute pitch and based on their relative pitch profile as early as the primary auditory cortex.

Prevalence of nonstenosing, complicated atherosclerotic plaques in cryptogenic stroke

OBJECTIVES

Our goal was to assess the prevalence of complicated American Heart Association (AHA) lesion type VI plaques in the carotid arteries of patients with cryptogenic stroke.

BACKGROUND

In up to 40% of ischemic stroke patients, no definite cause can be established despite extensive workup (i.e., cryptogenic stroke). To test the hypothesis if nonstenosing complicated carotid plaques may be the underlying etiology in some of these patients, we used high-resolution black-blood carotid magnetic resonance imaging (MRI), which can quantitatively assess plaque composition and morphology with good correlation to histopathology. Specifically, we focused on AHA type VI plaques, which are characterized by hemorrhage, thrombus, or fibrous cap rupture.

METHODS

Thirty-two consecutive patients (22 male; mean age 71.7 ± 11.9 years) with cryptogenic stroke and nonstenosing (<50%) eccentric carotid plaques were recruited from a single stroke unit. All patients underwent extensive clinical workup (brain MRI, duplex sonography, electrocardiography and Holter monitoring, transthoracic and transesophageal echocardiography, and laboratory investigations) to exclude other causes of stroke. All patients received a black-blood carotid MRI at 3-T with fat-saturated pre- and post-contrast T-1-, proton density-, and T-2-weighted and time-of-flight images using surface coils and parallel imaging techniques. Prevalence of AHA type VI plaque was determined in both carotid arteries on the basis of previously published MRI criteria.

RESULTS

AHA type VI plaques were found in 12 of 32 arteries (37.5%) ipsilateral to the stroke, whereas there were no AHA type VI plaques contralateral to the stroke (p = 0.001). The most common diagnostic feature of AHA type VI plaques was intraplaque hemorrhage (75%), followed by fibrous plaque rupture (50%) and luminal thrombus (33%).

CONCLUSIONS

This pilot study suggests that arterio-arterial embolism from complicated, nonstenosing carotid atherosclerotic plaques may play a role in a subgroup of patients previously diagnosed with cryptogenic stroke. To further evaluate the significance of AHA type VI plaques in cryptogenic stroke, future studies will have to analyze both clinical and imaging follow-up data, including event rates for secondary strokes.

Bindungsmuster von Cannabis- und Ecstasykonsumenten

Fragestellung: Frühere Studien haben einen Zusammenhang zwischen Opiatabhängigkeit und dem ängstlich-vermeidenden Bindungsmuster aufgezeigt. In dieser Studie soll explorativ untersucht werden, ob sich dieser Zusammenhang auch bei anderen Konsumentengruppen findet. Methode: Mit dem Bindungsinterview nach Bartholomew wurden die Bindungsmuster zweier Gruppen abhängig oder missbräuchlich Cannabis (N = 19) bzw. Ecstasy (N = 31) konsumierender Jungerwachsener untersucht, die einen möglichst „reinen“ Konsum der jeweiligen Substanz betrieben. Ergebnisse: Die Cannabisgruppe wies überwiegend abweisende und unerwartet häufig auch sichere Bindungsmuster auf. In der Ecstasygruppe traten alle Formen unsicherer Bindung gleich häufig, aber kaum sichere Bindungsmuster auf. Schlussfolgerungen: Die deutlichen Unterschiede zwischen den Gruppen sprechen gegen einen allgemeinen Zusammenhang eines einzelnen Bindungsmusters mit Substanzstörungen. In der Cannabisgruppe finden sich eine sichere und eine unsichere, überwiegend abweisende Untergruppe. Die Ergebnisse der Ecstasygruppe sprechen gegen einen einfachen Zusammenhang zwischen dem Konsum von Stimulanzien und einem anklammernd-aktivierendem Bindungsmuster, aber für eine deutliche klinische Auffälligkeit der Ecstasygruppe. Aufgrund des kleinen Stichprobe und des explorativen Charakters der Studie müssen die Ergebnisse an einem größeren Kollektiv repliziert werden.

Liquid-chromatographic profiling of Saponinum album (Merck)

Saponinum album (Merck) is a complex composite of triterpene saponins. It was shown that Saponinum album (Merck) dramatically enhances the toxicity of the N-glycosylase saporin from the seeds of Saponaria officinalis L. as well as the toxicity of a saporin based anti-tumor toxin. This study was intended to chromatographically profile the saponins present in Saponinum album (Merck) in order to identify saponins that determine the cytotoxicity enhancing properties of Saponinum album (Merck) on saporin. For this purpose a liquid-chromatographic profiling (HPLC) followed by ESI-TOF-MS analysis and evaluation of cytotoxicity enhancer effects of saponins from Saponinum album (Merck) was performed. This is the first study describing a liquid-chromatographic profiling of saponins from Saponinum album (Merck). Ten different saponins were isolated. There was a lot of variation observed in the cytotoxicity enhancing properties of different isolated saponins, 8 out of 10 isolated saponins showed an enhancer effect on the toxicity of saporin. Based on these results it was concluded that the cytotoxicity enhancer effect of Saponinum album (Merck) is not attributable to a single, activity determining saponin.

Rivalry between afterimages and real images: the influence of the percept and the eye

In binocular rivalry, the conscious percept alternates stochastically between two images shown to the two eyes. Both suppressed and dominant images form afterimages (AIs) whose strength depends on the perceptual state during induction. Counterintuitively, when these two AIs rival, the AI of the previously suppressed percept gains initial dominance, even when it is weaker. Here, we examined rivalry between afterimages, between real images, and between both to examine eye-based and binocular contributions to this effect. In all experiments, we found that for both AIs and real images, the suppressed percept consistently gained initial dominance following a long suppression period. Dominance reversals failed to occur following short suppression periods and depended on an abrupt change (removal) of the stimulus. With real images, results were replicated also when eye channels were exchanged during the abrupt change. The initial dominance of the weaker, previously suppressed percept is thus not due to its weaker contrast, to it being an afterimage, or to monocular adaptation effects as previously suggested. Instead, it is due to binocular, higher level effects that favor a perceptual switch after prolonged dominance. We discuss a plausible neural account for these findings in terms of neural interactions between binocular and eye-related stages.

Knowing with which eye we see: utrocular discrimination and eye-specific signals in human visual cortex

Neurophysiological and behavioral reports converge to suggest that monocular neurons in the primary visual cortex are biased toward low spatial frequencies, while binocular neurons favor high spatial frequencies. Here we tested this hypothesis with functional magnetic resonance imaging (fMRI). Human participants viewed flickering gratings at one of two spatial frequencies presented to either the left or the right eye, and judged which of the two eyes was being stimulated (utrocular discrimination). Using multivoxel pattern analysis we found that local spatial patterns of signals in primary visual cortex (V1) allowed successful decoding of the eye-of-origin. Decoding was above chance for low but not high spatial frequencies, confirming the presence of a bias reported by animal studies in human visual cortex. Behaviorally, we found that reliable judgment of the eye-of-origin did not depend on spatial frequency. We further analyzed the mean response in visual cortex to our stimuli and revealed a weak difference between left and right eye stimulation. Our results are thus consistent with the interpretation that participants use overall levels of neural activity in visual cortex, perhaps arising due to local luminance differences, to judge the eye-of-origin. Taken together, we show that it is possible to decode eye-specific voxel pattern information in visual cortex but, at least in healthy participants with normal binocular vision, these patterns are unrelated to awareness of which eye is being stimulated.

Systemische Therapie bei Substanzstörungen

Fragestellung: Nach der Anerkennung der ST durch den Wissenschaftlichen Beirat Psychotherapie (2009 ) stellt sich die Frage, wie die ST im ausdifferenzierten deutschen Suchthilfesystem stärker genutzt werden kann. Methodik: Dieser einleitende Artikel gibt einen kurzen Überblick über die Entwicklung und die evidenzbasierten Varianten der Systemischen Therapie (ST) im Bereich der Substanzstörungen. Ergebnisse: Die ST ist ein psychotherapeutisches Verfahren, das psychische Störungen in ihrem interaktionellen Kontext versteht und behandelt. Sie beschäftigt sich bereits seit über 40 Jahren mit der Therapie von Substanzstörungen, ausgehend von den frühen strukturell-strategischen Ansätzen über das klassisch systemische Mailänder Modell und lösungsorientierte Ansätze bis zu den in den letzten Jahren in den USA evaluierten ST-«Marken» wie Multidimensional Family Therapy, Multisystemic Therapy, Functional Family Therapy oder Brief Strategic Family Therapy. Schlussfolgerung: Die ST hat eine Vielzahl therapeutischer Konzepte zur Behandlung von Substanzstörungen entwickelt, die im deutschen Suchthilfesystem noch unzureichend genutzt werden.

Die Wirksamkeit Systemischer Therapie bei Substanzstörungen des Jugend- und Erwachsenenalters

Hintergrund: Systemische (Familien-, Paar-, Gruppen-, Multi-Familien-Gruppen-, Einzel-)Therapie ist in den USA und vielen europäischen Ländern ein anerkanntes und etabliertes Psychotherapieverfahren, in Deutschland jedoch erst seit 2008 wissenschaftlich anerkannt und bisher nur unzureichend in der klinischen Versorgung etabliert. Methode: Über Datenbankrecherchen und Querverweise in Metaanalysen und Reviews wurden alle bis Ende 2008 publizierten kontrollierten, randomisierten (oder parallelisierten) Outcome-Studien zur systemischen Therapie (alle Settings) bei ICD-10-/DSM-IV-Substanzstörungen des Erwachsenen- und des Jugendalters identifiziert und systematisch inhaltsanalytisch ausgewertet (Meta-Inhaltsanalyse). Ergebnisse: Es wurden 10 RCT zur systemischen Therapie bei Störungen des Erwachsenenalters und 17 RCT zum Jugendalter identifiziert – trotz internationaler Recherchen ausschließlich englischsprachige Publikationen. Sehr gut belegt ist die Wirksamkeit systemischer Familientherapie bei Substanzstörungen des Jugendalters, insbes. Cannabisstörungen (auch in Kombination mit dissozialen und/oder internalisierenden Störungen). Bei erwachsenen Heroinabhängigen ist ST kombiniert mit Methadonsubstitution nachweislich wirksamer als Methadonsubstitution allein. Weniger überzeugend ist die Evidenz zu Alkoholstörungen im Erwachsenenalter. Die Ergebnisse sind meist zeitlich stabil über Katamnese-Zeiträume von bis zu fünf Jahren. Schlussfolgerungen: Bei Substanzstörungen des Jugendalters ist systemische Therapie weltweit das am besten evaluierte Verfahren. In Bezug auf das Erwachsenenalter sind die Befunde auch positiv, aber weniger umfassend.

Eppendorfer Familientherapiestudie bei jungen Drogenabhängigen

Hintergrund: Die Eppendorfer Familientherapie (EFT; Thomasius, 2004 ) ist eine abstinenzorientierte, nicht-substituierende ambulante Frühintervention, die Elemente systemischer, lösungsorientierter und strukturell-strategischer Ansätze integriert. Methodik: Eine Stichprobe von N = 86 Familien mit einem drogenabhängigen Jugendlichen oder jungem Erwachsenen (14–25 Jahre) wurde in einem «prä–post»-Design mit Zwei-Jahres-Katamnese untersucht. Die Ergebnisse wurden mit den Daten entsprechender Referenzgruppen und einer in einer therapeutischen Gemeinschaft (TG) behandelten Vergleichsgruppe (N = 38) verglichen. Ergebnisse: Beide Behandlungsformen verbesserten den Suchtstatus, die psychische Symptombelastung und die familiären Beziehungen bei den Therapiebeendern. Zur Katamnese waren die Ergebnisse stabil oder zeigten weitere Verbesserungen. Die EFT erreichte eine Haltequote von 72 % (TG: 37 %). Schlussfolgerungen: Die Studie weist darauf hin, dass systemisch-familientherapeutische Ansätze auch bei jungen Drogenabhängigen in Deutschland erfolgreich eingesetzt werden können.

Non-invasive assessment of benign vocal folds lesions in children by means of ultrasonography

OBJECTIVES

Flexible fiberoptic endoscopes have made pediatric laryngeal examinations an everyday practice, even though fiberoptic-flexible laryngoscopy (FFL) is not always well tolerated in young children because of limited cooperation. Laryngeal ultrasonography (LUS) has been applied to normal and pathological findings in infants and children, allowing the assessment of subglottic hemangiomas, laryngeal stenosis and paralysis. No previous study assessed benign vocal folds lesions by LUS in children. The aim of this study is to evaluate the possibility of LUS to detect benign vocal fold lesions in children by comparing the results of FFL in 16 children with those of LUS.

METHODS

Sixteen children (9 males and 7 females) with a mean age of 7.5+/-4.0 years were included in the study. Each child underwent FFL performed by a skilled phoniatrician and LUS performed blindly by an expert radiologist.

RESULTS

On FFL bilateral vocal folds nodules were found in 9 patients, vocal fold cyst in 2 other patients, while in 2 children the vocal folds appeared normal. Laryngeal papyllomatosis, vocal fold polyp and vocal fold irregularity were found in only one patient. LUS enabled the diagnosis in all the 14 patients with vocal fold lesions. Bilateral hyperechoic lesions were visible in 10 patients, while hypoechoic lesions were found in three patients. No lesion were found in two children, while one patient presented with a monolateral hyperechoic lesion.

CONCLUSIONS

LUS was accurate, safe, well accepted and tolerated. LUS appears to be a useful diagnostic tool for supplementing FFL in the assessment of benign vocal fold lesions in children and may represent an interesting alternative in everyday clinical practice.

Voice after supracricoid laryngectomy: Subjective, objective and self-assessment data

Supracricoid laryngectomy (SCL) is an efficient surgical procedure for the treatment of selected laryngeal carcinoma, presently being performed not only in Europe but also in North America. The functional goals of the technique are voice and swallowing without a permanent tracheostoma. Perceptual and acoustic voice characteristics after SCL have been reported by different authors, but self-assessment data together with subjective and objective data have only been reported for a small number of subjects. Twenty male subjects, with a mean age of 71 years (range: 51-82 years) who underwent a SCL at least one year before our observation, were included in the study. Each subject underwent a flexible laryngoscopy and his voice was perceptually rated using the GRBAS scale. Objective examination included: maximum phonation time (MPT), voice spectrograms and syllable diadochokinesis on a single breath. Finally, each subject assessed his own voice using the Voice Handicap Index (VHI). The mean values of the GRBAS scale were respectively 2.4, 2.6, 2.4, 0.8, 0.5, 0.8. Mean MPT was 7.5 s, while for voice spectrograms the mean value of the Yanagihara scale was 3.7. Mean syllable diadochokinesis appeared as 3.3 syllables/s. Mean value of the VHI was 29.9. Subjective and objective data show a severely dysphonic voice after SCL; self-assessment data, on the contrary, reveal only moderate functional and emotional consequences. While perceptual, aerodynamic and acoustic data are in line with previous reports, self-assessment data were less severe in our subjects compared to what appears in the literature. It is concluded that self-assessment explores a different dimension of the patient's voice and that even if a severe dysphonia is present the consequences on everyday oral communication are only moderate.

Large area smoothing of surfaces by ion bombardment: fundamentals and applications

Ion beam erosion can be used as a process for achieving surface smoothing at microscopic length scales and for the preparation of ultrasmooth surfaces, as an alternative to nanostructuring of various surfaces via self-organization. This requires that in the evolution of the surface topography different relaxation mechanisms dominate over the roughening, and smoothing of initially rough surfaces can occur. This contribution focuses on the basic mechanisms as well as potential applications of surface smoothing using low energy ion beams. In the first part, the fundamentals for the smoothing of III/V semiconductors, Si and quartz glass surfaces using low energy ion beams (ion energy: ≤2000 eV) are reviewed using examples. The topography evolution of these surfaces with respect to different process parameters (ion energy, ion incidence angle, erosion time, sample rotation) has been investigated. On the basis of the time evolution of different roughness parameters, the relevant surface relaxation mechanisms responsible for surface smoothing are discussed. In this context, physical constraints as regards the effectiveness of surface smoothing by direct ion bombardment will also be addressed and furthermore ion beam assisted smoothing techniques are introduced. In the second application-orientated part, recent technological developments related to ion beam assisted smoothing of optically relevant surfaces are summarized. It will be demonstrated that smoothing by direct ion bombardment in combination with the use of sacrificial smoothing layers and the utilization of appropriate broad beam ion sources enables the polishing of various technologically important surfaces down to 0.1 nm root mean square roughness level, showing great promise for large area surface processing. Specific examples are given for ion beam smoothing of different optical surfaces, especially for substrates used for advanced optical applications (e.g., in x-ray optics and components for extreme ultraviolet lithography).

What we don't know about dysphagia complications?

Prevention of complications is the primary goal in patients with dysphagia. The most common complications of dysphagia are aspiration pneumonia, malnutrition and dehydration; other possible complications, such as intellectual and body development deficit in children with dysphagia, or emotional impairment and social restriction have not been studied thoroughly. Pulmonary complications of dysphagia should be viewed as an impaired balance between defence mechanisms (cough and mucociliary action, lymphatic clearance and cellular immune defences) and food and secretions aspiration. The main pulmonary complications are aspiration pneumonia, toxic aspiration syndromes, bacterial infections and pulmonary fibrosis. The risk of aspiration pneumonia is increased by poor oral status and health status, dependency for oral care and oral feeding; nonetheless, compliance with feeding recommendations of the dysphagia team, may reduce the risk of pulmonary complications. Malnutrition and dehydration are common in patients with dysphagia; however, enteral nutrition may significantly impact on both. Even though a relationship between malnutrition, dehydration and dysphagia exists, the real impact of one on the others is not known.

Adaptation and validation of the Italian MD Anderson Dysphagia Inventory (MDADI)

INTRODUCTION

Oropharyngeal dysphagia is a common symptom in patients with head and neck tumours. The MD Anderson Dysphagia Inventory (MDADI) is a questionnaire currently used in North America for the assessment of dysphagia-related disability in patients with head and neck cancer. The aim of the study is to analyze reliability and clinical validity of the Italian MDADI.

MATERIAL AND METHOD

48 persons with no history of dysphagia and 50 head and neck cancer patients with a chronic and stable dysphagia have been included in the study. Each subject completed alone the Italian MDADI twice with a week interval between the two questionnaire completion. Intra-subject reliability was analyzed through Pearson test in both groups of subjects. Clinical validity was calculated through the non parametric Mann Whitney test of the first MDADI assessment in both groups.

RESULTS

Internal consistency and test-retest reliability were high for each MDADI subscale in subjects without dysphagia as well as in those with dysphagia. The difference between MDADI values in subjects with and without dysphagia was significant for each subscale.

DISCUSSION

The Italian MDADI is reliable and clinically valid. The application of the MDADI is recommended in clinical practice as well as in descriptive, outcome and efficacy research.

Insecure family bases and adolescent drug abuse: A new approach to family patterns of attachment

A new approach to assessing family attachment patterns is presented, using a composite measure of individual attachment representations based on the Bartholomew Attachment Interview. A cluster analysis yielded three different patterns in a sample of N = 37 families with a drug dependent adolescent (age 14 - 25) and both biological parents. A "triangulated" pattern (mothers: preoccupied; fathers: dismissing; adolescents: fearful) was found in 65% of the sample. A total of 19% showed an "insecure" pattern (mothers, fathers, and adolescents: fearful) and 16% a "near-secure" pattern (mothers and adolescents: secure; fathers preoccupied). Preliminary comparisons between these groups indicate differences in comorbid psychiatric disorders, in individual and family functioning, but not in addiction severity. There is a trend towards differences in outcome of family therapy. Implications for treatment and further research are discussed.

Preliminary considerations on the application of the voice handicap index to paediatric dysphonia

Dysphonia is a common paediatric condition. Adult voices are usually evaluated using a set of minimal basic measurements including: endoscopic examination, aerodynamics, perception, acoustics, and self-assessment by the patient. The Voice Handicap Index is the most widely used self-assessment tool, but its use in the paediatric setting has never been reported. Aim of this study was to report Voice Handicap Index ratings in a group of dysphonic children, multi-modally assessed before and after voice therapy. The study involved 28 children (16 female, 12 male, mean age 10.9 years (range 6-12)) presenting chronic hoarseness due to vocal fold nodules (18 cases), unilateral localised oedema (6 cases) or recurrent laryngeal paralysis (4 cases). All received voice therapy for 5-6 months, and underwent voice assessments based on video-endoscopy ratings (size of nodule/ oedema or glottic closure in the case of recurrent laryngeal paralysis), maximum phonation time, GIRBAS scale, spectrograms and a perturbation analysis. All patients also completed the Voice Handicap Index. Aerodynamic, acoustic, perceptual and self-assessment data, before and after voice therapy, were compared using Wilcoxon's test and Student's t test. Correlations between the Voice Handicap Index domains were measured by means of Pearson's correlation coefficient. Post-treatment measurements showed that the nodules/oedema had decreased in size in 18 children following therapy, and two subjects with recurrent laryngeal paralysis showed improved glottic closure. Mean maximum phonation time increased slightly, but the difference was not significant. There was a general reduction in perceptual severity, but this was only significant for parameters G, B and A. Spectrographic analysis showed no significant improvement and, although the mean perturbation analysis values improved, only the difference in jitter values was significant (p = 0.016). Voice Handicap Index was applicable in all cases, and showed a clear and significant improvement (p = 0.0006). The correlations between the three Voice Handicap Index factors were close; no correlation was found between the functional domain and the physical and emotional domains. The Voice Handicap Index is a useful tool in children with dysphonia, but an adapted version validated for paediatric patients is essential.

On the ability of ultrasound parametric perfusion imaging to predict the area of infarction in acute ischemic stroke

PURPOSE

Cerebral perfusion deficits in acute ischemic stroke can be detected by means of transcranial harmonic imaging after ultrasound contrast agent bolus injection. We evaluated five different parameters of the bolus kinetics as parametric images and correlated areas of disturbed perfusion with the area of definite infarction.

MATERIALS AND METHODS

Perfusion harmonic imaging after SonoVue bolus injection (BHI) was used to investigate 22 patients suffering from acute internal carotid artery infarction. For each subject, we calculated five different images based on the following parameters from the time-intensity curve in each pixel: pixelwise peak intensity (PPI), area under the curve (AUC), positive gradient (PG), time to peak (TTP), and a three factor image from the factor analysis of medical image sequences (FAMIS). The findings in the diencephalic imaging plane were compared with the definite area of infarction, as diagnosed by cranial CT.

RESULTS

In predicting the definite area of infarction in follow-up CT, we found the following sensitivities and positive predictive values (PPV): PPI (100 %/95 %), AUC (100 %/90 %), FAMIS (89 %/89 %), PG (84 %/94 %) and TTP (47 %/100 %). The areas of disturbed perfusion in all five types of parametric images correlated significantly with the area of infarction in CT. Images from the FAMIS algorithm and PPI images showed the highest Spearman rank correlation with the area of definite infarction as displayed in CT (both r = 0.76, p < 0.001). Images from the other parameters correlated as follows: PG: r = 0.62 (p = 0.003), AUC: r = 0.53 (p = 0.014), TTP: r = 0.50 (p = 0.021).

CONCLUSION

BHI can detect disturbed perfusion in acute hemispheric stroke. In their ability to predict the development of an infarction, intensity-based parameters and FAMIS were determined to have a high sensitivity, and TTP was found to have a high PPV and specificity.

[Satisfaction with penetrating keratoplasty. Results of a questionnaire census]

BACKGROUND

Penetrating keratoplasty (PKP) is commonly referred to as the most successful transplantation procedure in medicine. This appraisal, however, is currently poorly supported by evidence. The aim of our study was to collect data on patient satisfaction with PKP as well as to analyze factors predisposing to dissatisfaction.

PATIENTS AND METHODS

In the years 1988-2002 a total of 3,219 PKPs were performed on 2,981 patients. These patients were sent a questionnaire. The items pertained to subjective assessment of visual quality as compared to the situation before PKP and about regretting the PKP.

RESULTS

The questionnaire was answered by 1,142 patients (59% of the traceable persons). The mean follow-up was 3.3+/-2.9 years. Indications for PKP were Fuchs' endothelial dystrophy (26%), keratoconus (23%), bullous keratopathy (15%), and further indications (36%). For these groups, best corrected visual acuity improved by more than two lines in 51, 80, 42, and 50%, respectively. The percentage of subjective improvement of vision was 73, 78, 47, and 63%. The percentage of regretting the PKP was 12, 4, 27, and 10%, respectively. All differences were highly statistically significant. Significant influencing factors on regretting the PKP were (inversely sorted for relevance): repeat graft failure, bullous keratopathy, contact lens wear, paresthesia, removal of running sutures, and patient age.

CONCLUSIONS

General satisfaction with PKP is high. An important exception is bullous keratopathy, most likely due to accompanying morbidity (e.g., cystoid macular edema).

Age at diagnosis of deaf babies: a retrospective analysis highlighting the advantage of newborn hearing screening

OBJECTIVE

Aim of the study was to assess the mean age at diagnosis of bilateral congenital hearing loss in the Audiology and Phoniatry Centre of the University of Turin, pointing out, by North-West Italy experience, the role of the newborn hearing screening in anticipating the age of diagnosis.

METHODS

This was a retrospective study. Forty-six congenital deaf babies were reviewed and age at diagnosis was assessed for each, taking in consideration the role of hearing loss risk factors. Eighteen babies (39%) were sent by the centres that participate to the newborn hearing screening program while 28 (61%) came for parental or pediatrician suspicion of hearing loss and for general language delay. Sixteen babies (35%) presented risk factors for hearing loss.

RESULTS

The mean age of identification of severe to profound hearing loss was 20.5 months (S.D.=15.3) in the whole group; considering the group of 28 babies not screened the mean age was 29.3 months (S.D.=13.4). This value decreased to 6.8 months (S.D.=3.6) in the group which underwent screening programme. This difference was statistically significant at Student's t-test (p<0.001). The average ages of diagnosis for healthy versus high risk children were significantly different only in the group of screened babies (p<0.05).

CONCLUSIONS

Childhood hearing impairment is one of the most common of congenital disorders, and even though there is a general trend of early identification, in reality age of diagnosis is as yet still too late even in developed countries. Our results show that newborn hearing screening could reduce the age at which infants with hearing loss are diagnosed and treated; this would improve speech, language, auditory outcome and the quality of parents and infant life.

Attachment and substance use disorders: A review of the literature and a study in drug dependent adolescents

Earlier studies on attachment and substance use disorders using the Hazan and Shaver (1987) self-report mainly indicate a link with "avoidant" attachment styles. Studies working with the Adult Attachment Interview (Main & Goldwyn, 1998) have produced inconsistent results. The present study used the Bartholomew (1990) interview coding system to assess attachment in a sample of 71 German opiate using, drug dependent adolescents (DDAs, age 14 - 25) and 39 non-clinical controls. Fearful attachment was predominant in DDAs, while controls were predominantly secure. Severity of drug use, as assessed with the European Addiction Severity Index (Gsellhofer, Fahrner, & Platt, 1994) and urinalyses, was positively correlated with fearful attachment, but negatively correlated with dismissing attachment. The presence of comorbid psychiatric disorders was associated with fearful attachment but not with addiction severity.

Intensity and fundamental frequency control in tracheoesophageal voice

Tracheo-oesophageal voice prostheses are currently widely used following total laryngectomy. Data on maximum phonation time and spectrum have been studied by various Authors and are well known. On the contrary, intensity and fundamental frequency control have received little attention. Intensity and fundamental frequency play an important role in the prosodic aspects of speech. Fundamental frequency variations have been studied in tone language speakers, but the ability to voluntarily change intensity and fundamental frequency remain to be fully investigated. Aim of the present study was to analyse the ability of tracheo-oesophageal voice users to change intensity and fundamental frequency. A total of 12 male subjects who underwent total laryngectomy, in whom a tracheo-oesophageal prosthesis had been inserted, were considered. Maximum phonation time was calculated. Each subject was asked to utter an /a/ as loud as possible and an /a/ as soft as possible. Each subject was then asked to utter an /a/ at comfortable pitch and then at an interval of a fifth. Intensity as well as fundamental frequency variations were compared using Wilcoxon signed rank test. Correlation between maximum phonation time and variation in intensity and in fundamental frequency as well as between the two latter variables was calculated using Spearman's rank correlation coefficient. Mean maximum phonation time was 8 (+/- 3.8) sec. Mean energy was 50 (+/- 4.8) dB SPL for soft phonation and 68 (+/- 4.7) dB SPL for loud phonation. The difference observed was statistically significant (p < 0.02). Mean fundamental frequency values were 106 (+/- 14) Hz and 135 (+/- 34) Hz at the interval of a fifth. The difference observed was statistically significant (p < 0.02). Tracheo-oesophageal voice users were able to change intensity and fundamental frequency, but their control was rather poor. Variations in intensity, as well as fundamental frequency, did not show any correlation with maximum phonation time, and were not correlated with each other. In conclusion, the tracheo-oesophageal voice allows small fundamental frequency variations, but their control appears difficult. On the contrary, intensity variations appear larger and control somewhat easier.

Familientherapie als Frühintervention bei drogenabhängigen Jugendlichen, jungen Erwachsenen und deren Müttern - Effektstärken und individuelle Verbesserungsquoten bei den Therapie-Beendern

Zusammenfassung: Fragestellung: Welche kurzfristigen Effekte einer familientherapeutischen Frühintervention (der «Eppendorfer Familientherapie») bei Familien mit einem polytoxikoman drogenabhängigen Jugendlichen bzw. jungen Erwachsenen sind in einer multikriterialen Evaluation beobachtbar? Methodik: Die eingesetzte Familientherapie ist ambulant und abstinenz-orientiert. Das Design ist prospektiv, naturalistisch und misst prä-post-Effekte. Es beginnen 86 Familien die Therapie (86 drogenabhängige Indexpatienten, IP, im frühen Suchtstadium, 76 Mütter, 57 Väter, 36 Geschwister). Zu 5 Zielkriterien werden intraindividuelle Verbesserungsquoten von IP und Müttern berichtet (Sucht-Status, Familienfunktion, Psychopathologie, Psychosoziale Integration, Therapiezufriedenheit), jeweils in Patientenangaben und Expertenbeurteilungen. Ergebnisse: Die Behandlung haben n = 62 (72%) der IP regulär beendet. Bei 45 dieser 62 (73%) ergeben sich signifikante intraindividuelle Besserungen im Sucht-Status. IP und Mütter weisen in allen Zielkriterien Verbesserungen auf. Schlussfolgerungen: Polytoxikoman drogenabhängige Jugendliche im frühen Suchtstadium, die noch in Kontakt mit ihrer Herkunftsfamilie stehen, profitieren von ambulanter familientherapeutischer Frühintervention.

Role of videoendoscopy in phoniatrics: data from three years of daily practice

Phoniatrics is the medical specialty involved in the management of communication and swallowing disorders. Videoendoscopy plays an important role in the assessment of various disorders in the clinical practice of phoniatrics: the voice as well as the speech and swallowing mechanisms can be analysed through this procedure. Aim of the study is to describe videoendoscopic application in daily phoniatric practice: data on 1627 participants, consecutively examined, are reported. A total of 2004 videoendoscopy examinations were performed between March 1999 and December 2002. Study population comprising 1627 patients (716 male, 911 female); age ranged from 0.6 to 97 years. The following parameters were considered: a) function to be assessed through videoendoscopy (voice, speech, swallowing, other); b) phoniatric nosological chapter in participants with a recognized disease; c) age of participant; d) occupation of participant; d) medical discipline related to disease identified. Three populations were analysed: study population (1627 subjects), subjects requiring phoniatric consultation for voice and swallowing assessment. The participants examined endoscopically required a phoniatric consultation in order to have a voice or a swallowing assessment, respectively, in 67% and 20% of the cases. In 411 out of 1095 (37.5%) voice evaluations, no disorder was identified, while in most of the swallowing assessments (93.1%), a clear dysphagic disorder was detected. A bimodal distribution appeared in the 1627 participants and in the voice population with a first peak at age 20-40 years and a second peak at age 50-70. In the swallowing population, the number of participants examined appeared to increase with age. In the swallowing population, pensioners and clerks represent almost 80% of the population; in the total population, as well as in the voice populations, pensioners as well as teachers, singers and students are well represented. In most cases (52.5%), no clear disease was present. The two areas of disease most represented were otorhinolaryngology and neurology.

[AWMF-guideline: cocaine-, amphetamine-, ecstasy- and hallucinogen-related disorders]

Actually, guidelines for treatment of substance-related disorders were written under the overall control of the DG-Sucht e. V. and the DGPPN e. V. This appears within the framework of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaft (AWMF). The leading objective of these guidelines is the description of the current scientifically proven and evidence-based medicine in addiction to derive recommendations to therapy. In this context, the guideline for treatment of cocaine-, amphetamine-, ecstasy-, and halluzinogen-related disorders is introduced.

Treatment of phonic tics in patients with Tourette's syndrome using botulinum toxin type A

We assessed the effect of botulinum toxin type A (BTX-A) on phonic tics in patients with Tourette's syndrome. A total of 30 patients received 2.5 IU BTX-A (BOTOX; Allergan) in both vocal cords. All patients were assessed after 15 days and then 4 times over a 12-month period. At each visit the following data were collected: phenomenology of tics, global impression of changes by physician and patient, number of BTX-A injections given, interval between injections, time to response, duration of response, presence of post-injection hypophonia and side effects, presence of premonitory sensory tic component, and interference with social life and work or school activities. Vocal tics improved after treatment in 93% patients, with 50% being tic-free. Mean response time was 5.8 days, and mean duration of response was 102 days. Quality of life improved, and premonitory experiences dropped from 53% to 20%. Hypophonia was the only side effect of note (80% of patients). BTX-A is an effective and safe treatment for phonic tics associated with Tourette's syndrome.