Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study

BACKGROUND

Staging of non-small cell lung cancer (NSCLC) is important for determining choice of treatment and prognosis. The accuracy of FDG-PET scans for staging of lymph nodes is too low to replace invasive nodal staging. It is unknown whether the accuracy of integrated FDG-PET/CT scanning makes invasive staging redundant.

METHODS

In a prospective study, the mediastinal and/or hilar lymph nodes in patients with proven NSCLC were investigated with integrated FDG-PET/CT scanning. Pathological confirmation of all suspect lymph nodes was obtained to calculate the accuracy of the fusion images. In addition, the use of the standardised uptake value (SUV) in the staging of intrathoracic lymph nodes was analysed.

RESULTS

105 intrathoracic lymph node stations from 52 patients with NSCLC were characterised. The prevalence of malignancy in the lymph nodes was 36%. The sensitivity of the integrated FDG-PET/CT scan to detect malignant lymph nodes was 84% and its specificity was 85% (positive likelihood ratio 5.64, negative likelihood ratio 0.19). SUV(max), SUV(mean) and the SUV(max)/SUV(liver) ratio were all significantly higher in malignant than in benign lymph nodes. The area under the receiver operating curve did not differ between these three quantitative variables, but the highest accuracy was found with the SUV(max)/SUV(liver) ratio. At a cut-off value of 1.5 for the SUV(max)/SUV(liver )ratio, the sensitivity and specificity to detect malignant lymph node invasion were 82% and 93%, respectively.

CONCLUSION

The accuracy of integrated FDG-PET/CT scanning is too low to replace invasive intrathoracic lymph node staging in patients with NSCLC. The visual interpretation of the fusion images of the integrated FDG-PET/CT scan can be replaced by the quantitative variable SUV(max)/SUV(liver) without loss of accuracy for intrathoracic lymph node staging.

Chronic obstructive pulmonary disease as a risk factor for stroke-related seizures

Chronic obstructive pulmonary disease (COPD) is a risk factor for cardiovascular disorders and different types of stroke. The present retrospective study investigates whether COPD is also a risk factor for the development of seizures in stroke patients. The study population consisted of 237 patients with stroke-related seizures. The control population was composed of 939 patients, admitted for a stroke between 2002 and 2004 and who did not develop epileptic spells on a follow up of 2 years. The stroke type and aetiology, and the vascular risk factors, including COPD, were compared. The seizure patients were older (P = 0.009) and had more arterial hypertension (P = 0.046) and cardiac-embolic strokes (P = 0.045) than the control group. On logistic regression only partial anterior circulation syndrome/infarct (PACS/I) and COPD (P < 0.001) emerged as independent risk factors for the development of seizures in stroke patients. The occurrence of seizures was not related to the severity of the COPD or to its type of treatment. The present study confirms that seizures occur most frequently in patients with a PACS/I. Although we were unable to demonstrate why COPD is a risk factor for seizures in stroke patients, its frequent associated nocturnal oxygen desaturation seems to be the most plausible explanation. Further prospective are needed to assess the role of COPD as a possible independent risk factor for stroke-related seizures.

Seizures and epilepsy in patients with lacunar strokes

BACKGROUND

The relation between seizures and small subcortical infarcts is uncertain. The present retrospective study investigates whether differences are observed between patients with and without seizures following a lacunar stroke.

PATIENTS AND METHODS

Thirty-seven patients with seizures and a prior history of a lacunar stroke were admitted to the Ghent University Hospital during 2000 and 2005. They were compared to 205 patients, admitted between 2002 and 2004, with an acute lacunar stroke and without epileptic spells on follow-up. Nine out of the 37 patients with seizures and 48 out of the 205 without seizures had a history of recurrent strokes.

RESULTS

No differences in vascular risk factors, distribution and frequency of the lacunes, degree of severity of the white matter changes and outcome were observed. On the Mini-Mental State Examination moderate to severe cognitive disturbances were observed in the seizure group and in some patients of the non-seizure group.

CONCLUSIONS

In the present study we found no evidence that seizures are directly induced by lacunar infarcts. The seizures appear to be part of a more global ongoing cerebral disorder probably leading to cognitive impairment.

Stability of upper incisor inclination changes in Class II division 2 patients

The aim of this study was to evaluate the changes in incisor inclination following orthodontic treatment in Class II division 2 patients, and to assess the long-term stability after retention. Dental casts and cephalograms of 61 Class II division 2 patients (31 males and 30 females, mean age 13.4 years) with a closed lip seal were available before (T1), at the end of treatment (T2), and 3.5 years (mean) post-treatment (T3). A method of measuring upper incisor inclination on dental casts was developed for the purpose of the investigation. This involved placing markers on the study casts and then taking radiographs which were measured to establish the upper incisor inclination. Statistical analysis of the data included the calculation of mean values, standard deviation, standard errors, and ranges for each variable. Spearman ranked correlation coefficients were computed for selected model variables and scattergrams plotted. To investigate the influence of the chosen retention therapy, a Mann-Whitney U-test was used. The mean change in incisor inclination during orthodontic treatment was 15.2 degrees. There was a mean relapse of 2.2 degrees between T2 and T3, but this was not considered clinically relevant. The amount of relapse was independent of the type of the retention appliance (Hawley type retainer or lingual retainer). The relationship between long-term stability of the incisor inclination and between the lip line relative to the upper incisors was also investigated, based on cephalometric data. A mean decrease in lip line height of 0.6 mm was seen at T2 and, although the observed change was statistically significant, it would not be clinically relevant.

Free radical scavengers are more effective than indomethacin in the prevention of experimentally induced heterotopic ossification

The pathogenesis of heterotopic ossification is still unclear and the preventive therapies are usually insufficient. The present study was designed to investigate the possible preventive effect of free radical scavengers on the development of experimentally induced heterotopic ossification in a rabbit model and to compare free radical scavengers with indomethacin to determine whether they act synergistically. A standard immobilization-manipulation model was used to induce heterotopic ossification in the hind legs of 40 1-year-old female New Zealand albino rabbits. The animals were divided into four groups and received daily either placebo, a free radical scavenger cocktail [allopurinol and N-acetylcysteine (A/A)], indomethacin or the combination of A/A and indomethacin in a randomized double-blind fashion. Every 4 days an X-ray was taken and the thickness and length of new bone formation was measured at the thigh. A marked statistically significant difference was found between the four groups. In the groups that received A/A, either alone or combined with indomethacin, an inhibition of bone growth, both in thickness and in length was demonstrated. In this experimental model free radical scavengers had a superior inhibitory effect on heterotopic ossification than indomethacin. Free radicals could play an important role in the pathogenesis of heterotopic ossification.

Magnetic Resonance Imaging after Seizures in Patients with an Ischemic Stroke

BACKGROUND

Seizures related to ischemic strokes are harmful. Their pathogenesis is not very well understood. The present study investigates whether diffusion-weighted imaging (DWI) can detect if those seizures are due to recurrent infarction or responsible for secondary ischemic changes.

PATIENTS AND METHODS

DWI was obtained within 8 days in 60 patients with seizures (7 early and 53 late onset) related to an ischemic stroke.

RESULTS

In 30 patients, positive DWI with decreased apparent diffusion coefficient was found. In 11 patients with late-onset seizures, the DWI showed a positive rim, surrounding the old infarct, while in 12 patients a large positive zone corresponding to a new infarct was observed. All 7 patients with early-onset seizures had positive DWI corresponding to the establishing infarct. A large positive zone on DWI was mainly observed in cardioembolic stroke.

CONCLUSIONS

The positive rim around the old infarct can be considered as cytotoxic edema. Recurrent acute infarction, mainly of cardioembolic origin, seems to be a significant cause of so-called late-onset seizures, making the subdivision into early- and late-onset seizures arbitrary.

Differentiation of chronic sinus diseases by measurement of inflammatory mediators

BACKGROUND

Chronic rhinosinusitis (CRS) clinically is a heterogeneous group of sinus diseases, which may cover different disease entities, or may represent a disease continuum. Studying inflammatory cells and mediators in clearly defined disease subgroups may lead to a better differentiation of chronic sinus diseases.

METHODS

Sinonasal mucosal tissue from 10 nasal polyp (NP) patients, 13 cystic fibrosis patients (CF-NP), eight CRS subjects without polyps, and nine control patients were stained for CD3, CD25, CD68, CD20, myeloperoxidase (MPO), CD138 and tissue homogenates were assayed for eotaxin, interleukin (IL)-1beta, IL-2sRalpha, IL-5, interferon (IFN)-gamma, IL-8, transforming growth factor (TGF)-beta1, tumor necrosis factor-alpha, and MPO by enzyme-linked immunosorbent assay or UNICAP system.

RESULTS

Nasal polyp and CF-NP showed increased numbers and activation of T cells, while only NP displayed an increase in plasma cells. Nasal polyp had significantly higher levels of eosinophilic markers [eosinophils, eotaxin, and eosinophil cationic protein (ECP)] compared with CRS, controls and CF-NP. Chronic rhinosinusitis was characterized by a Th1 polarization with high levels of IFN-gamma and TGF-beta, while NP showed a Th2 polarization with high IL-5 and immunoglobulin (Ig) E concentrations. Nasal polyp and CF-NP were discriminated by edema from CRS and controls, with CF-NP displaying a very prominent neutrophilic inflammation.

CONCLUSION

Based on cellular and mediator profiles, we suggest that CRS, NP, and CF-NP are distinct disease entities within the group of chronic sinus diseases.

EEG Findings after a Cerebral Territorial Infarct in Patients Who Develop Early- and Late-Onset Seizures

BACKGROUND

EEG findings are generally not considered to be very helpful for the diagnosis of poststroke seizures.

PURPOSE

This retrospective study investigates the EEG characteristics in patients who develop seizures after a cerebral territorial infarct.

PATIENTS AND METHODS

The study population consisted of 110 patients with seizures after a cerebral territorial infarct (12 with early- and 98 with late-onset seizures) and 275 without. All 110 patients had an interictal EEG after their first seizure. The EEG patterns after the stroke were compared between those available from 69 patients who developed seizures and those from 275 who did not. Also the EEG patterns after the seizure (n = 110) were compared to those in the poststroke group without subsequent seizures.

RESULTS

Periodic lateralized epileptic discharges (PLEDs) on the EEG after stroke were only found in 5.8% of the patients with early- and late-onset seizures. They were absent in the stroke group without seizures. Frontal intermittent rhythmic delta activities (FIRDAs) were observed in 24.6% of the seizure group, compared to 1.1% in the control group. Diffuse slowing occurred also significantly more often in the former (21.7%) compared to the latter group (5.1%). Normal EEG findings were seen in 53.8% of the stroke patients without seizures, compared to 8.5% in those with seizures. The incidence of focal slowing was the same in both groups. Similar findings were observed when comparing the EEG patterns of the patients after the first poststroke seizure to those of the stroke group without subsequent seizures. In patients with early-onset seizures, PLEDs or FIRDAs were present in 25% each. FIRDAs and diffuse slowing were significantly more frequently observed on the poststroke EEGs of patients who developed late-onset seizures.

CONCLUSIONS

FIRDAs, PLEDs and diffuse slowing are the most frequent EEG findings in patients with early-onset seizures. Patients with FIRDAs and diffuse slowing on the poststroke EEG have a high risk to develop late-onset seizures, while the chance is reduced in those with normal EEG findings.

Computed tomographic changes of the brain and clinical outcome of patients with seizures and epilepsy after an ischaemic hemispheric stroke

It is not well established whether seizures and epilepsy after an ischaemic stroke increase the disability of patients. Seventy-two patients with delayed seizures after a hemispheric infarct (37 with a single seizure and 35 with epilepsy) were included in the study. The modified Rankin scale was used to compare disability of the patients at 1 month after stroke and at 2 weeks after single or the last seizure, in case of epilepsy. The size of the X-ray hypoattenuation zone was compared on computed tomographic (CT) scans, performed in the weeks after the stroke and 1 week after single or repeated seizures. Lesion size was determined by superimposing the CT slices on digital cerebral vascular maps, on which the contours of the infarct area were delineated. The extent of the infarcts was expressed as the percentage fraction of the total surface area of the cerebral hemisphere. Groups with a single seizure and with epilepsy were mutually compared. Infarcts predominated in the parieto-temporal cortical regions. In the overall group the median Rankin score worsened significantly after seizures. The average size of the X-ray hypoattenuation zone was also significantly increased on the CT scans after the seizures, compared with those after stroke, without clear evidence of recent infarction. Mutual comparison of patients with a single seizure episode and of those with epilepsy showed only a trend of more severe disability and of increase in lesion size in the post-stroke epilepsy group. Delayed seizures and epilepsy after ischaemic stroke are accompanied by an increase in lesion size on CT and by worsening of the disability of the patients. This study does not allow to determine whether this is due to stroke recurrence or due to additional damage as a result of the seizures themselves.

Delayed transient worsening of neurological deficits after ischaemic stroke

BACKGROUND

Although the causes of stroke recurrence are well known, no particular study deals with the specific issue of late-onset transient worsening of the neurological deficit (TWND) after an ischaemic stroke.

PATIENTS AND METHODS

In this retrospective study the aetiology of the TWNDs in 101 patients was compared to the causes of transient ischaemic attacks (TIAs) in 115 patients. All patients had a full cardiovascular and neuroimaging examination according to current guidelines. An electroencephalogram (EEG) was performed when necessary. The diagnosis of inhibitory seizures was retained when the EEG showed periodic lateralized epileptiform discharges or intermittent rhythmic delta activities, or when the patient developed typical seizures afterwards.

RESULTS

Arterial hypertension and diabetes were more prevalent vascular risk factors in TWND patients. Small-vessel disease and inhibitory seizures were a more frequent cause of TWNDs than of TIAs. Extracranial large-vessel disease predominates in TIA patients. The global prevalence of cardiac diseases as cause of TIAs and TWNDs was the same, although severe ulcerous plaques of the aortic arch and patent foramen ovale with atrial septum aneurysm occurred more frequently in TWND patients.

CONCLUSIONS

The most frequent causes of late-onset TWNDs were different from those of TIAs. Apart from repeated neuroimaging of the brain, exhaustive cardiac investigations and EEG are mandatory in TWND patients.

The influence of articular morphology on non-traumatic degenerative changes of the distal radioulnar joint. A radiographic study

We examined 248 wrist X-rays of patients over 50 years of age to find out if ulnar variance, orientation of the sigmoid notch and ulnar head inclination play a role in the development of non-traumatic osteoarthritis of the distal radioulnar joint. Minor degenerative changes, viz. focal joint space narrowing and/or lipping, or small osteophytes at the inferior edge of the ulnar head, were present in 13% of the X-rays of these wrists. They were significantly more frequent in wrists with a more inclined ulnar head and significantly less present in wrists with an oblique, distally orientated sigmoid notch. There was no significant association with ulnar variance or age. This study suggests that articular morphology may play a role in the development of degenerative changes of the distal radioulnar joint.

Cerebral blood flow and oxygen metabolism in symptomatic internal carotid artery occlusion by (traumatic) cervical artery dissection

The present study investigates whether cerebral infarction resulting from internal carotid artery occlusion by cervical dissection is due to emboli, released from a superimposed luminal thrombus, or is due to haemodynamic failure and hypoperfusion. Ten patients with a history of stroke and with a visible cerebral infarct on computed tomographic scan, due to cervical dissection and thrombosis of the internal carotid artery, were studied with positron emission tomography in order to assess the regional cerebral blood flow (rCBF), the regional cerebral metabolic rate of oxygen (rCMRO2) and the regional oxygen extraction fraction (rOEF) in different regions of the brain. rCBF and rCMRO2 were only decreased in the infarct area but not in the peri-infarct zone or elsewhere in the brain. As rOEF was not increased in the affected cerebral hemisphere, the present study suggests artery-to-artery embolism rather than a haemodynamic event as the cause of the stroke. Use of anticoagulants thus appears to be the appropriate treatment in the acute stage.

Clinical predictors of late-onset seizures and epilepsy in patients with cerebrovascular disease

BACKGROUND

Seizures and epilepsy are harmful and worsen the disability of stroke patients. There are currently no good clinical predictors of late-onset seizures and epilepsy in patients with cerebrovascular disease (CVD).

PATIENTS AND METHODS

110 patients with delayed seizures after an ischaemic or a haemorrhagic stroke, a transient ischaemic attack or a subarachnoid haemorrhage (60 with a single seizure and 50 with epilepsy) and 366 without seizures were included in this retrospective study. The clinical syndrome, the stroke aetiology and the vascular risk factors were compared. The groups with a single seizure and with epilepsy were also analysed separately.

RESULTS

There were no differences in age, gender, aetiology and vascular risk factors between the groups with and without seizures. When comparing the incidence of the clinical syndromes, ischaemic partial anterior circulation syndrome (PACS) was significantly more and transient ischaemic attack less frequent in the group with seizures compared to the control group. The severity of the neurological impairment on admission and the degree of disability on discharge after a PACS was similar in those who developed late-onset seizures compared with those who did not. Also on the Cox proportional hazards analysis, PACS appeared to be the only clinical risk factor for development of seizures and epilepsy in patients with CVD. No differences were observed in clinical predictors between patients with a single seizure and those with epilepsy.

CONCLUSION

PACS is the only independent predictor for the occurrence of late-onset seizures in patients with CVD.

Comparison of age of onset and development of motor complications between smokers and non-smokers in Parkinson's disease

BACKGROUND

There is growing evidence from case-control and from cohort studies that smoking is inversely related to the risk of developing Parkinson's disease (PD). However, it is still controversial if PD starts at an older age in ever-smoking patients compared to never-smoking ones.

PATIENTS AND METHODS

The present retrospective study compares in a large series of 512 out-patients, collected over the last 24 years, the age of onset of the complaints, the age at which PD was diagnosed and the start of levodopa treatment between ever- and never-smokers. Also, the occurrence of long-term side-effects of the drug was evaluated. 184 PD patients with a history of smoking were compared with 328 who had never smoked. The subgroups with and without a family history of PD were analysed separately.

RESULTS

In the overall ever-smoking group, as well as in the subgroup without a family history, the onset of the disease and the time of the diagnosis of PD and the time at which levodopa was started occurred at an older age than in the never-smoking group. This difference could not be demonstrated in the patients with a family history, due to the low number of cases and the lack of statistical power. Although the follow-up period was the same in both study groups, motor fluctuations and dyskinesia were more frequent and appeared earlier after levodopa treatment in the non-smoking compared to the ever-smoking PD patients. Only for cognitive impairment there was a non-significant trend in the smoking group.

CONCLUSION

The present study confirms the protective action of smoking on PD and also suggests some modulating effect of smoking on the dopaminergic system.

Cerebral bloodflow and oxygen metabolism in borderzone and territorial infarcts due to symptomatic carotid artery occlusion

It remains controversial whether borderzone infarcts are due to compromised cerebral perfusion and whether territorial infarcts are caused by artery-to-artery emboli in case of occlusion of the internal carotid artery. The present positron emission tomography study compares with normal controls, the average regional cerebral bloodflow (rCBF), regional oxygen extraction fraction (rOEF) and regional cerebral metabolic rate for oxygen (rCMRO(2)) in the infarct area, the peri-infarct zone, the remaining homolateral hemisphere and in the contralateral hemisphere of 10 patients with borderzone and 17 patients with territorial infarcts, due to internal carotid artery occlusion by atherosclerosis and by cervical dissection. The steady-state technique with oxygen-15 was used. A nearly significant increase of rOEF with lowered rCBF and rCMRO(2) was observed in the peri-infarct zone of patients with territorial infarcts. In patients with borderzone infarcts rCMRO(2) was decreased in the peri-infarct zone, in the remaining homolateral hemisphere and in the contralateral hemisphere without changes in rCBF and rOEF. The present study finds no arguments that impaired cerebral perfusion is a more frequent cause of borderzone than of territorial infarcts.

The prognostic significance of changes in lesion size of established cerebral infarcts on computed tomography of the brain

BACKGROUND

As a second part of our prospective study, we assessed the size of the infarct lesion on computed tomography (CT) of the brain at two fixed time points after stroke in order to investigate its influence on the clinical outcome.

METHODS

From 220 consecutive stroke patients, admitted within 24 h after onset with symptoms lasting more than 24 h, we selected 150 displaying an anterior circulation infarct or syndrome. All included patients had CT scans without contrast enhancement on day 3 (+/- 8 h) and on day 10 (+/- 8 h) after stroke onset. The size of the X-ray hypoattenuation zone was determined by superimposing the CT slices on digital cerebral vascular maps, on which the contours of the infarct area were delineated. The lesion size was expressed as the fraction of the total surface area of these digital cerebral maps. The patients were divided into four groups according to their degree of disability at 3 months on the modified Rankin (R) scale as follows : R 0-1, R 2-3, R 4-5, R 6.

RESULTS

There was a clear association between lesion size on CT, on day 3 and on day 10, and the clinical outcome. Lesion size decreased between day 3 and day 10 in the groups R 0-1 and R 2-3, remained unchanged in the group R 4-5 and further increased in group R 6.

CONCLUSION

Lesion size on CT is a significant predictor of stroke outcome. It decreases from day 3 to day 10 in patients with no or low disability at 3 months, but increases in those who do not survive their stroke.

The prognostic significance of changes in X-ray attenuation on CT in established cerebral infarcts

BACKGROUND

X-ray hypoattenuation on computed tomography (CT) reflects the severity of ischaemic damage after stroke. However, the clinical syndrome and the effect of time influence the visibility of infarcts. This prospective study analyses whether the degree of hypoattenuation on CT at two time intervals after stroke has a predictive value for the clinical outcome.

METHODS

220 consecutive stroke patients were admitted within 24 h after onset with symptoms lasting more than 24 h. The study was restricted to 150 patients displaying an anterior circulation infarct or syndrome. All patients had CT scans without contrast enhancement on day 3 (+/-8 h) and day 10 (+/-8 h) after stroke onset. The degree of X-ray attenuation expressed in Hounsfield units was determined in the centre of the infarct area and compared to that in the corresponding zone of the contralateral hemisphere. The patients were divided into four groups according to their degree of disability at 3 months on the modified Rankin scale as follows: R 0-1, R 2-3, R 4-5 and R 6.

RESULTS

Patients in groups R 4-5 and R 6 had the most severe impairment on admission. The average decrease of X-ray attenuation on CT on day 3 was less in patients in group R 0-1, but was not different between the three other groups, while it was significantly correlated with the severity of the disability on day 10. CT X-ray attenuation increased between days 3 and 10 in group R 0-1, was unchanged in group R 2-3 and further decreased in groups R 4-5 and R 6.

CONCLUSION

The degree of X-ray attenuation on CT on day 3 allows us to distinguish those patients who will recover more or less completely from those with definite disability, while the CT findings on day 10 allow a more precise prediction of outcome. Increase of X-ray attenuation on day 10 is known as the fogging effect and appears to be a favourable prognostic factor. Fogging is generally considered to be due to macrophage invasion and proliferation of capillaries within the infarct area, but probably also represents partial restoration of some viable tissue.

Influence of posture on haemodynamics, sodium and hormonal homeostasis in cirrhotic patients with and without ascites

BACKGROUND/AIMS

Previous studies in preascitic cirrhosis demonstrated sodium retention during upright posture and sodium hyperexcretion during bed-rest. In patients with ascites, sodium excretion and creatinine clearance decreased during upright posture. Head-down tilting (HDT) accentuated the natriuretic effect of bed-rest in short term studies. The aim of this study was to evaluate the effects of prolonged change in posture on sodium homeostasis and on haemodynamics in cirrhotic patients.

METHODS

Eighteen cirrhotic patients (9 with, 9 without ascites), were studied during 12 h upright, supine and HDT position (-10 degrees). During each position, 12 h urine collections were performed and blood samples were obtained before and after change in position. Non-invasive systemic hemodynamic measurements were performed.

RESULTS

There was no significant difference between HDT and supine position in both ascitic and preascitic groups for urinary volume, fractional sodium excretion, creatinine clearance, urinary and plasma hormones and hemodynamics. Urinary volume (in supine and HDT) and fractional sodium excretion (in supine) were significantly higher and urinary noradrenaline and plasma renin (in supine and HDT) significantly lower in the preascitic group compared with the ascitic patients. Cardiac output and heart rate decreased after 12 h supine and HDT, suggesting a deactivation of sympatic nervous system and catecholamines.

CONCLUSION

Our results demonstrate that prolonged HDT had no advantage over normal bed-rest in both patient groups. Possibly, a short-term beneficial effect of HDT was lost after several hours.

Fast withdrawal from benzodiazepines in geriatric inpatients: a randomised double-blind, placebo-controlled trial

OBJECTIVE

We have previously demonstrated that temporary substitution with a low-dose hypnosedative drug may lead to successful withdrawal from chronic benzodiazepine (BZD) use in the majority of patients admitted to a geriatric ward. In the present study, a withdrawal programme was evaluated in which the habitual treatment with BZDs was replaced by either 1 mg lormetazepam or placebo, defining withdrawal success rate, sleep quality and withdrawal symptoms as main outcomes.

METHODS

The target population was geriatric inpatients who had been taking BZDs for at least 3 months. Subjects suffering from mental disorders were excluded. Lormetazepam or placebo were randomly assigned and given in a double-blind fashion. After 1 week, the replacement therapy was discontinued. Subjective estimations of sleep quality and withdrawal symptoms were registered at predefined intervals, four times in a period of 30 days, using standard questionnaires (the Pittsburgh Sleep Quality Index and the Benzodiazepine Withdrawal Symptom Questionnaire, respectively).

RESULTS

The success rate was significantly higher in the lormetazepam substitution group (80% vs 50% in the placebo group, P < 0.05). Both the subjective quality of sleep and withdrawal symptoms were significantly better in the lormetazepam substitution group. Important withdrawal effects were observed in the control group in two patients with a history of chronic alcohol abuse.

CONCLUSIONS

Initial replacement therapy with a low-dose BZD is preferred over placebo, since the latter alternative is associated with worse sleep quality and a lower success rate. Placebo must only be used under medical scrutiny, given the potential for unmasking delirious symptoms, especially in patients with concomitant alcoholism.

The Dynamic Patient Simulator: learning process, first results and students' satisfaction

The Dynamic Patient Simulator (DPS) is an interactive case-program. After solving the case, third year medical students filled in an anonymous questionnaire. In this study we tried to have insight in the students' learning process and satisfaction. First results are presented. It seems that the implementation of the case was experienced as positive. The time aspect should be scheduled better and students should have as much time as they want to solve the case.