The discrepancy between recommendations and clinical practice for viscosupplementation in osteoarthritis: mind the gap!

Recently AAOS, ACR and OARSI revised their recommendations for the management of knee osteoarthritis (OA) and for hand, knee and hip joints. During ISIAT (International Symposium on Intra-Articular Treatments) 2013 round table on recommendations about the use of intra-articular Hyaluronic Acid (IAHA) in OA, several considerations were elaborated by the ISIAT Technical Expert Panel (TEP) regarding discrepancy between recommendations and clinical practice. The ISIAT TEP gathered the following eight suggestions regarding the drawing of recommendations on the use of IAHA in OA and its comparison with other treatments. It is necessary to merge data coming from both RCTs and registers. Only studies with a strong level of evidence should be taken into account. A common threshold of efficacy should be assessed for comparing treatments. Evaluation of hard outcomes is essential. The effect size of placebo as comparator should be attentively considered in RCTs. Particular attention should be given to different phenotypes of OA that may possibly respond differently to each treatment. Compliance and long-term side effects of different therapeutic approaches should be evaluated. Pharmacoeconomic evaluation should be performed on the long term.

Association of MDR-TB isolates with clinical characteristics of patients from Northern region of India

PURPOSE

We sought to determine the characteristics and relative frequency of transmission of MDR-TB in North India and their association with the clinical and epidemiological characteristics of TB-patients.

MATERIALS AND METHODS

To achieve the objectives PCR-SSCP, MAS-PCR and direct DNA sequencing were used against 101 Mycobacterium tuberculosis isolates.

RESULTS

Multidrug-resistant-TB isolates were found to be significantly higher (P=0.000) in previously treated patients in comparison to newly diagnosed patients. Further, significant differences (P=0.003) were observed between different age groups (Mean±SD, 28.6±11.77) of the TB patients and multidrug resistance. Most frequent mutations were observed at codons 531 and 315 of rpoB and katG genes, respectively, in MDR-TB isolates.

CONCLUSION

Routine surveillance of resistance to anti-TB drugs will improve timely recognition of MDR-TB cases and help prevent further transmission in Northern India.

Design and operation of a fast electromagnetic inductive massive gas injection valve for NSTX-U

Results from the operation of an electromagnetic valve, that does not incorporate ferromagnetic materials, are presented. Image currents induced on a conducting disc placed near a pancake solenoid cause it to move away from the solenoid and open the vacuum seal. A new and important design feature is the use of Lip Seals for the sliding piston. The pressure rise in the test chamber is measured directly using a fast time response Baratron gauge. The valve injects over 200 Torr l of nitrogen in less than 3 ms, which remains unchanged at moderate magnetic fields.

Establishing and managing a periodontal biobank for research: the sharing of experience

Periodontal bio-repositories, which allow banking of clinically validated human data and biological samples, provide an opportunity to derive biomarkers for periodontal diagnosis, prognosis and therapeutic activities which are expected to improve patient management. This article presents the establishing of the Malaysian Periodontal Database and Biobank System (MPDBS) which was initiated in 2011 with the aim to facilitate periodontal research. Partnerships were established with collaborating centres. Policies on specimen access, authorship and acknowledgement policies were agreed upon by all participating centres before the initiation of the periodontal biobank. Ethical approval for the collection of samples and data were obtained from institutional ethics review boards. A broad-based approach for informed consent was used, which covered areas related to quality of life impacts, genetics and molecular aspects of periodontal disease. Sample collection and processing was performed using a standardized protocol. Biobanking resources such as equipment and freezers were shared with the Malaysian Oral Cancer Database and Tissue Bank System (MOCDTBS). In the development of the MPDBS, challenges that were previously faced by the MOCDTBS were considered. Future challenges in terms of ethical and legal issues will be faced when international collaborations necessitate the transportation of specimens across borders.

The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively

This study evaluated whether obese patients who lost weight before their total joint replacement and kept it off post-operatively were at lower risk of surgical site infection (SSI) and re-admission compared with those who remained the same weight. We reviewed 444 patients who underwent a total hip replacement and 937 with a total knee replacement who lost weight pre-operatively and sustained their weight loss after surgery. After adjustments, patients who lost weight before a total hip replacement and kept it off post-operatively had a 3.77 (95% confidence interval (CI) 1.59 to 8.95) greater likelihood of deep SSIs and those who lost weight before a total knee replacement had a 1.63 (95% CI 1.16 to 2.28) greater likelihood of re-admission compared with the reference group. These findings raise questions about the safety of weight management before total replacement of the hip and knee joints.

The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively

This study evaluated whether obese patients who lost weight before their total joint replacement and kept it off post-operatively were at lower risk of surgical site infection (SSI) and re-admission compared with those who remained the same weight.

We reviewed 444 patients who underwent a total hip replacement and 937 with a total knee replacement who lost weight pre-operatively and sustained their weight loss after surgery. After adjustments, patients who lost weight before a total hip replacement and kept it off post-operatively had a 3.77 (95% confidence interval (CI) 1.59 to 8.95) greater likelihood of deep SSIs and those who lost weight before a total knee replacement had a 1.63 (95% CI 1.16 to 2.28) greater likelihood of re-admission compared with the reference group.

These findings raise questions about the safety of weight management before total replacement of the hip and knee joints.

Cite this article: Bone Joint J 2014;96-B:629–35.

p190-B RhoGAP regulates the functional composition of the mesenchymal microenvironment

Hematopoiesis is regulated by components of the microenvironment, so-called niche. Here, we show that p190-B GTPase-activating protein (p190-B) deletion in mice causes hematopoietic failure during ontogeny, in p190-B(-/-) fetal liver and bones, and in p190-B(+/-) adult bones and spleen. These defects are non-cell autonomous, as we previously showed that transplantation of p190-B(-/-) hematopoietic cells into wild-type (WT) hosts leads to normal hematopoiesis. Coculture of mesenchymal stem (MSC)/progenitor cells and wild-type bone marrow (BM) cells reveals that p190-B(-/-) MSCs are dysfunctional in supporting hematopoiesis owing to impaired Wnt signaling. Furthermore, p190-B loss causes alteration in BM niche composition, including abnormal colony-forming unit (CFU)-fibroblast, CFU-adipocyte and CFU-osteoblast numbers. This is due to altered MSC lineage fate specification to osteoblast and adipocyte lineages. Thus, p190-B organizes a functional mesenchymal/microenvironment for normal hematopoiesis during development.

Mal-united fracture of calcaneum treated with lateral decompression

Fracture calcaneum is commonly complicated with mal-union. Mal-union is usually presented with broadening of the lateral wall of the calcaneum, irregularity of the sub-talar joint and loss of the vertical height of the body of calcaneum with varus rotation. In this study twenty three (n=23) patients underwent a lateral decompression for pain on lateral aspect of foot on walking and tip toeing, secondary to a mal-united calcaneal fracture with or without sub-talar intra-articular involvement. Almost every patient had ballooned out body of calcaneum with impingement of peroneal tendon sheath with its content and lateral heel pain as a result of deformity. So in current study the operative procedure selected was excision of a lateral calcaneal bony mass and decompression of the peroneal tendon to relieve pain. Peroneal tenogram was a routine procedure before surgery to detect presence and site of blockade within tendon sheath. The average follow-up was for a period of 31.6 months. Result was assessed according to American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Scale. Two patients (n=2, 8.69%) had excellent (Category 1) result, seventeen (n=17, 73.9%) were good (Category 2), two (n=2, 8.69%) were fair (Category 3) and rest two (n=2, 8.69%) were with poor (Category 4) outcome. Every four out of five patients got back painless Heel and Ankle after surgery. The results suggest that the lateral decompression procedure is a technically simpler yet viable alternative to late sub-talar fusion for lateral pain following a mal-united fracture of calcaneum.

Diagnostic options for radiative divertor feedback control on NSTX-U

A radiative divertor technique is used in present tokamak experiments and planned for ITER to mitigate high heat loads on divertor plasma-facing components (PFCs) to prevent excessive material erosion and thermal damage. In NSTX, a large spherical tokamak with lithium-coated graphite PFCs and high divertor heat flux (q(peak) ≤ 15 MW/m(2)), radiative divertor experiments have demonstrated a significant reduction of divertor peak heat flux simultaneously with good core H-mode confinement using pre-programmed D(2) or CD(4) gas injections. In this work diagnostic options for a new real-time feedback control system for active radiative divertor detachment control in NSTX-U, where steady-state peak divertor heat fluxes are projected to reach 20-30 MW/m(2), are discussed. Based on the NSTX divertor detachment measurements and analysis, the control diagnostic signals available for NSTX-U include divertor radiated power, neutral pressure, spectroscopic deuterium recombination signatures, infrared thermography of PFC surfaces, and thermoelectric scrape-off layer current. In addition, spectroscopic "security" monitoring of possible confinement or pedestal degradation is recommended. These signals would be implemented in a digital plasma control system to manage the divertor detachment process via an actuator (impurity gas seeding rate).

Suction elevator for ear surgery

An instrument has been designed to combine a suction and an elevator for use in ear surgery.

Macular pigment optical density in wet age-related macular degeneration among Indians

PURPOSE

To estimate the value of macular pigment optical density (MPOD) in adult south Indian population with wet age-related macular degeneration (AMD).

METHODS

A total of 33 patients with wet AMD and 29 age-matched controls >50 years of age underwent MPOD measurement with the macular densitometer. The patients were also tested for their dietary intake of carotenoids, smoking history, and lifetime UV exposure.

RESULTS

The mean MPOD values in the Indian population with wet AMD was 0.23 (95% CI: 0.18-0.29) vs control was 0.43 (95% CI: 0.37-0.49), P<0.0001, at 0.5° eccentricity. Ex-smokers had a lower MPOD than non-smokers (0.16 (0.09-0.23) vs 0.28 (0.22-0.34), P=0.026) and the lowest level of carotenoids intake had 48% lower MPOD than the highest level (0.14 (0.08-0.21) vs 0.33 (0.24-0.43), P=0.012). There was no significant age-related decline or gender variation in MPOD.

CONCLUSION

This study establishes the MPOD in adult Indian population with wet AMD, with a lack of macular pigment in association with wet AMD.

Treatment consent capacity in patients with traumatic brain injury across a range of injury severity

OBJECTIVE

To investigate medical decision-making capacity (MDC) in patients with acute traumatic brain injury (TBI) across a range of injury severity.

METHODS

We evaluated MDC cross-sectionally 1 month after injury in 40 healthy controls and 86 patients with TBI stratified by injury severity (28 mild [mTBI], 15 complicated mild [cmTBI], 43 moderate/severe [msevTBI]). We compared group performance on the Capacity to Consent to Treatment Instrument and its 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, severe impairment) on the consent standards were also assigned to each participant with TBI using cut scores referenced to control performance.

RESULTS

One month after injury, the mTBI group performed equivalently to controls on all consent standards. In contrast, the cmTBI group was impaired relative to controls on the understanding standard. No differences emerged between the mTBI and cmTBI groups. The msevTBI group was impaired on almost all standards relative to both control and mTBI groups, and on the understanding standard relative to the cmTBI group. Capacity compromise (mild/moderate or severe impairment ratings) on the 3 clinically complex standards (understanding, reasoning, appreciation) occurred in 10%-30% of patients with mTBI, 50% of patients with cmTBI, and 50%-80% of patients with msevTBI.

CONCLUSIONS

One month following injury, MDC is largely intact in patients with mTBI, but is impaired in patients with cmTBI and msevTBI. Impaired MDC is prevalent in acute TBI and is strongly related to injury severity.

Association between various types of obesity and macular pigment optical density

PURPOSE

To elucidate the association between macular pigment optical density (MPOD) and various types of obesity in the South-Indian population.

PATIENTS AND METHODS

In total, 300 eyes of 161 healthy volunteers of South-Indian origin were studied. MPOD was measured psychophysically at 0.25°, 0.50°, 1.00°, and 1.75° eccentricities from fovea. Anthropometric measurements included waist circumference (WC) and waist-to-hip ratio (WHR) and body mass index (BMI). Using the WHO Expert Consultation guidelines, obesity was defined based on BMI alone (BMI ≥ 23 kg/m(2)), based on WC alone (WC ≥ 90 cm for men and ≥ 80 cm for women), and based on WHR alone (≥ 0.90 for men and ≥ 0.85 for women). Isolated generalized obesity was defined as increased BMI and normal WC. Isolated abdominal obesity was defined as increased WC and normal BMI. Combined obesity was defined as increased BMI and increased WC.

RESULTS

Mean MPOD at all eccentricities was not significantly different between men and women. Mean MPOD values did not significantly differ in various types of obesity, when compared with the normal subjects. On subgroup analysis, in age group ≥ 60 years, mean MPOD values were significantly higher in subjects with obesity based on BMI (0.61 vs 0.41, P=0.036), obesity based on WHR (0.67 vs 0.41, P=0.007), and isolated generalized obesity (0.66 vs 0.41, P=0.045) in comparison with normal subjects at 0.25° eccentricity.

CONCLUSION

We found lack of an association between MPOD and obesity in the South-Indian population. A similar finding was also noted on age group- and gender-wise analyses.

High-frequency hearing loss among mobile phone users

The objective of this study is to assess high frequency hearing (above 8 kHz) loss among prolonged mobile phone users is a tertiary Referral Center. Prospective single blinded study. This is the first study that used high-frequency audiometry. The wide usage of mobile phone is so profound that we were unable to find enough non-users as a control group. Therefore we compared the non-dominant ear to the dominant ear using audiometric measurements. The study was a blinded study wherein the audiologist did not know which was the dominant ear. A total of 100 subjects were studied. Of the subjects studied 53% were males and 47% females. Mean age was 27. The left ear was dominant in 63%, 22% were dominant in the right ear and 15% did not have a preference. This study showed that there is significant loss in the dominant ear compared to the non-dominant ear (P < 0.05). Chronic usage mobile phone revealed high frequency hearing loss in the dominant ear (mobile phone used) compared to the non dominant ear.

The role of sensation in subjective and objective evaluation of nasal patency

To assess if sensation of nasal mucosa affect the subjective sensation of nasal patency. This is a case control study with 50 patients, using 2% lignocaine as the active drug and normal saline as the placebo (2 groups of 25 patients each). Each subject had 2 ml of solution sprayed into the test nose. These subjects had no prior nasal symptoms, allergy or surgery. They were evaluated subjectively using Likert scale and objectively by acoustic rhinometry before and after lignocaine or normal saline. The patients in both normal saline and lignocaine groups demonstrated no significant change based upon Likert scale. The study also demonstrated the mean cross sectional area 1 (CSA1), mean cross sectional area 2 (CSA2), with mean Volume 1 and mean Volume 2, these results did not vary significantly in both groups with Acoustic Rhinometry. The analysis thus shows that the use of topical anesthetic spray on nasal mucosa produces no objective effect on nasal resistance or subjective sensation of altered nasal patency. Thus the study concludes that, tactile sensation of nasal mucosa does not play a role in the sensation of nasal obstruction.

MTHFR A1298C polymorphism and idiopathic male infertility

BACKGROUND

DNA methylation is an important epigenetic feature of DNA that plays a pivotal role in gene expression regulation during spermatogenesis. The enzyme methylenetetrahydrofolate reductase (MTHFR) catalyses the formation of folate intermediates that are vital for DNA synthesis and methylation reactions. C677T and A1298C variants of MTHFR result in reduced plasma folate and increase the susceptibility to various multifactorial disorders. We have already shown that homozygosity for 677 (C ®T) mutation in the MTHFR gene, is a risk factor for idiopathic male infertility in an Indian population.

AIM

Recently, we showed that homozygosity for the 677(C;T) mutation in the MTHFR gene is a risk factor for idiopathic male infertility and now we aim to assess whether the A1298C mutation in the same gene is an additional risk factor for idiopathic male infertility in an Indian population.

SETTING AND DESIGNS

In a case-control study 151 idiopathic male infertile patients and 140 healthy fertile control individuals were recruited from the University hospital and infertility clinics in Varanasi city, India.

MATERIALS AND METHODS

Genotyping for A1298C change of the MTHFR gene was done by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Statistical Analysis : Allele frequencies were calculated using Fisher's exact test. Odds ratio was calculated as the measure of the association between the MTHFR genotype and idiopathic male infertility.

RESULTS

The homozygous (C/C) A1298C polymorphism of the MTHFR gene was present at a statistically high significance in idiopathic azoospermic infertile men (OR=3.4494, CI: 1.0092 to 11.7899, P<0.05).

CONCLUSION

The MTHFR 1298CC genotype is an additional genetic risk factor for idiopathic male infertility in an Indian population.

Nose pads

An idea to fix broken nose pads of spectacles has been suggested.

Production and validation of Putonghua- and Cantonese-Chinese language National Institutes of Health Stroke Scale training and certification videos

BACKGROUND AND PURPOSES

The National Institutes of Health Stroke Scale (NIHSS) is an integral part of acute stroke assessment. We report our experience with new Putonghua- and Cantonese-Chinese language NIHSS (PC-NIHSS and CC-NIHSS) training and certification videos.

METHODS

A professional video production company was hired to create the training and certification videos for both PC-NIHSS and CC-NIHSS. Two training and certification workshops were held in Chengdu and Beijing, and two workshops in Hong Kong. The instruction, training and group A certification videos were presented to workshop attendees. Unweighted kappa statistics were used to measure the agreement among raters, and the inter-rater agreements for PC-NIHSS and CC-NIHSS videos were compared with those of original English language NIHSS (E-NIHSS) videos.

RESULTS

The pass rates using PC-NIHSS and CC-NIHSS videos were 79% and 82%, respectively. All possible responses on individual scale items were included. Facial palsy and limb ataxia (13%) showed poor agreement, nine (60%) to 10 (67%) items showed moderate agreement (0.4<kappa<0.75), and three (20%) to four (27%) items showed excellent agreement. When compared with E-NIHSS videos, the agreements on best gaze, visual fields, facial weakness and aphasia were less for PC-NIHSS videos, and the agreements on commands for level of consciousness and visual fields were less for CC-NIHSS videos. Nevertheless, there was no difference between PC-NIHSS or CC-NIHSS and E-NIHSS videos in the agreement on total score.

CONCLUSIONS

Compared with E-NIHSS videos, PC-NIHSS and CC-NIHSS videos show good content validity and inter-rater reliability. Availability of these videos may facilitate the proper use of NIHSS among physicians and nurses in Putonghua- or Cantonese-speaking communities.

Demonstration of Tokamak ohmic flux saving by transient coaxial helicity injection in the national spherical torus experiment

Transient coaxial helicity injection (CHI) started discharges in the National Spherical Torus Experiment (NSTX) have attained peak currents up to 300 kA and when coupled to induction, it has produced up to 200 kA additional current over inductive-only operation. CHI in NSTX has shown to be energetically quite efficient, producing a plasma current of about 10 A/J of capacitor bank energy. In addition, for the first time, the CHI-produced toroidal current that couples to induction continues to increase with the energy supplied by the CHI power supply at otherwise similar values of the injector flux, indicating the potential for substantial current generation capability by CHI in NSTX and in future toroidal devices.

Hypertensive retinopathy and sensorineural hearing loss

OBJECTIVE

To determine the correlation between hypertensive retinopathy (which is the end-organ damage of the vessels due to chronic hypertension) with sensorineural hearing loss.

METHODS

Pure tone hearing threshold of 56 hypertensive patients were compared with 56 normal age and sex matched control. Comparisons of pure tone hearing threshold are made among different group (grade) of hypertensive retinopathy patients and control (non-hypertensive patients).

RESULTS

The mean hearing thresholds were higher (worse) in all the frequencies on both sides in the hypertensive study group compared with normal subjects. However it was found to be statistically significant when tested using independent sample test (p < 0.05) on right ear at 2,000 Hz, 4,000 Hz and 8,000 Hz only. The mean hearing threshold is higher in all frequencies in the presence of retinopathy compared to control. However, the difference was found to be only statistically significant in the mean hearing threshold between grade I and control at 4,000 Hz and 8,000 Hz on both sides and at 1,000 Hz and 2,000 Hz on right ear. Hypertensive patient with grade I retinopathy had higher pure tone hearing thresholds at 4,000 Hz and 8,000 Hz compared to hypertensive without retinopathy and normal control.

CONCLUSIONS

Hypertensive retinopathy appears to be associated with high frequency sensor neural hearing loss.

Visual analog scale in hearing loss

OBJECTIVE

To determine if visual analog scale (VAS) that has been used to measure magnitude of internal states such as pain, mood and various functional capabilities can be applied for patients with hearing loss.

MATERIALS AND METHODS

One hundred and sixty patients, aged 12-80 years with unilateral hearing loss were studied using a VAS (1-10) and pure tone audiometry (PTA) of responses to 500, 1,000 and 2,000 Hz to determine degree and type of hearing loss. The results of both were compared to determine if VAS can be used in measuring hearing loss.

RESULTS

Patients with mild, moderate hearing loss correlate well with corresponding VAS but other degrees of hearing loss (severe and profound) have poor correlation. The best correlation between PTA and VAS were found in conductive type of hearing loss.

CONCLUSION

This study suggest that there may be a role for VAS in mild and moderate hearing loss. This may be more applicable in rural setting as a screening procedure when audiometry is not available and can enhance clinical hearing assessment especially in mild-to-moderate conductive hearing loss.

Surgical management of large acoustic neuromas: a review

Acoutic neuromas operated at UMMC from 2001 to 2006 were retrospectively reviewed. There were a total of 27 cases. All tumors were large, measuring more than 2 cm. Hearing loss was the most common presenting symptom (63%), followed by headache (52%), dysequilibrium (30%), facial numbness (30%), tinnitus (26%) and gait disturbances (15%). Eleven (41%) of patients had hydrocephalus at the time of presentation, for which a shunt procedure was required. The translabrynthine (TL) approach was used for 12 patients and the retrosigmoid (RS) with or without presigmoid clearance for the remaining 15. Major complications included one mortality and three cerebrovascular accidents (CVA's). The one-year facial nerve outcome was good to acceptable in 62% (House-Brackmann Grade I - IV) of patients. A literature review of current management of acoustic neuromas is presented.

Localisation of quantitative trait loci for quality attributes in a doubled haploid population of wheat (Triticum aestivum L.)

Selection of wheat germplasm for a range of quality traits has been a challenging exercise because of the cost of testing, the variation within testing data, and a poor understanding of the underlying genetics. The objective of this study was to identify quantitative trait loci (QTLs) underlying quality traits in wheat. A doubled haploid population comprising 190 lines from Chara/WW2449 was grown in two different environments and evaluated for various quality traits. A molecular map comprising 362 markers based upon simple sequence repeat, sequence tagged microsatellite, glutenin, and DArT loci was constructed and subsequently exploited to identify QTLs using a whole-genome approach. Fifteen QTLs that were consistent in the two different environments were identified for thousand kernel mass, grain protein content, milling yield, flour protein content, flour colour, flour water absorption, dough development time, dough strength (extensograph height and resistance at 5 cm), and dough extensibility (extensograph length) using the whole genome average interval mapping approach. The amount of genetic variation explained by individual QTLs ranged from 3% to 49%. A number of QTLs associated with dough strength, dough extensibility, dough development time, and flour water absorption were located close to the glutenin Glu-B1 locus on chromosome 1B. Identification of the chromosomal location and effect of the QTLs influencing wheat quality may hasten the development of superior wheats for target markets via marker-assisted selection.

Cerebrospinal fluid otorrhoea from an abnormal communication between the internal auditory meatus and the medial wall of the tympanic cavity

Patients who have had middle-ear or mastoid surgery are at an increased risk of developing cerebrospinal fluid (CSF) otorrhoea. The CSF leak is usually from defects in the tegmen or posterior cranial fossa. We present a patient with CSF otorrhoea following a modified radical mastoidectomy seven years ago. There was an unusual communication between the internal auditory meatus (IAM) and the middle ear. Radiologic imaging like the MRI is useful in identifying the site of leak.

Outcome of patients presenting with idiopathic facial nerve paralysis (Bell's palsy) in a tertiary centre--a five year experience

This is a retrospective study. The objective of this study is to review the factors influencing the outcome of treatment for the patients presented with idiopathic facial nerve paralysis. The demographic data, clinical presentation and management of 84 patients with idiopathic facial nerve paralysis (Bell's palsy) were collected from the medical record office, reviewed and analyzed from 2000 to 2005. Thirty-four (72.3%) out of 47 patients who were treated with oral prednisolone alone, fully recovered from Bell's palsy meanwhile 36 (97%) out of 37 patients who were treated with combination of oral prednisolone and acyclovir fully recovered. The difference was statistically significant. 42 (93.3%) out of 45 patients who presented within three days to our clinic, fully recovered while 28 (71.8%) out of 39 patients presented later then three days had full recovery from Bell's palsy. The difference was statistically significant. The outcome of full recovery is better with the patients treated with combined acyclovir and prednisolone compared with prednisolone alone. The patients who were treated after three days of clinical presentation, who were more than 50 years of age, who had concurrent chronic medical illness and facial nerve paralysis HB Grade IV to VI during initial presentation have reduced chance of full recovery of facial nerve paralysis.

Medical decision-making capacity in mild cognitive impairment: a 3-year longitudinal study

OBJECTIVE

To investigate longitudinal change in the medical decision-making capacity (MDC) of patients with amnestic mild cognitive impairment (MCI) under different consent standards.

METHODS

Eighty-eight healthy older controls and 116 patients with MCI were administered the Capacity to Consent to Treatment Instrument at baseline and at 1 to 3 (mean = 1.7) annual follow-up visits thereafter. Covariate-adjusted random coefficient regressions were used to examine differences in MDC trajectories across MCI and control participants, as well as to investigate the impact of conversion to Alzheimer disease on MCI patients' MDC trajectories.

RESULTS

At baseline, MCI patients performed significantly below controls only on the three clinically relevant standards of appreciation, reasoning, and understanding. Compared with controls, MCI patients experienced significant declines over time on understanding but not on any other consent standard. Conversion affected both the elevation (a decrease in performance) and slope (acceleration in subsequent rate of decline) of MCI patients' MDC trajectories on understanding. A trend emerged for conversion to be associated with a performance decrease on reasoning in the MCI group.

CONCLUSIONS

Medical decision-making capacity (MDC) decline in mild cognitive impairment (MCI) is a relatively slow but detectable process. Over a 3-year period, patients with amnestic MCI show progressive decline in the ability to understand consent information. This decline accelerates after conversion to Alzheimer disease (AD), reflecting increasing vulnerability to decisional impairment. Clinicians and researchers working with MCI patients should give particular attention to the informed consent process when conversion to AD is suspected or confirmed.

Mammalian sex chromosomes. IV. Replication heterogeneity in the late replicating facultative- and constitutive-heterochromatic regions in the X chromosomes of the mole rats, Bandicota bengalensis and Nesokia indica

The karyotypes of Nesokia indica and Bandicota bengalensis are identical except for their sex chromosomes, which are much larger in Nesokia due to additional constitutive heterochromatin (C.H.). Replication patterns of their sex chromosomes were studied employing 3H-Tdr autoradiography and BrdUrd-FPG staining techniques. Though the "conservative" part of both early- and late-replicating X chromosomes revealed identical replication patterns in most cells, deviant patterns of only the late replicating X chromosome were encountered in approximately 10% cells. Surprisingly, these late-X variants were similar in the two species. The sex chromosome-associated C.H. segments replicated late in S-phase and, in females, the homologous heterochromatin replicated asynchronously--the later replicating one was predominantly associated with the late X. These results suggest structural and functional conservation of the X chromosomes as well as the possible influence of facultative heterochromatin (F.H.) on the replication of associated C.H. in these two species.

Chorda tympani nerve function after myringoplasty

This is a cross-sectional study design aimed to determine the prevalence of Chorda Tympani Nerve (CTN) injury and related symptoms following myringoplasty. Thirty patients were included in this study. The methods used were measuring taste thresholds using electrogustometer to map taste threshold on the anterior two-third of the tongue on the operated side with the non operated side as the control. Reading is taken when the subject experiences sour/metallic taste. All corresponding threshold values and findings were recorded and compared to control. Results showed 50% of patients had elevated threshold levels suggestive of CTN injury. However, none of the patients reported subjective taste loss. This study concludes that the prevelance rate of CTN injury in post myringoplasty patients is about 50% but this is not associated with altered taste sensation.

Medical decision-making capacity in patients with mild cognitive impairment

OBJECTIVES

To empirically assess the capacity of patients with amnestic mild cognitive impairment (MCI) to consent to medical treatment under different consent standards (Ss).

METHODS

Participants were 56 healthy controls, 60 patients with MCI, and 31 patients with mild Alzheimer disease (AD). Each participant was administered the Capacity to Consent to Treatment Instrument (CCTI) and a comprehensive neuropsychological battery. Group differences in performance on the CCTI and neuropsychological variables were examined. In addition, the capacity status (capable, marginally capable, or incapable) of each MCI participant on each CCTI standard was examined using cut scores derived from control performance.

RESULTS

Patients with MCI performed comparably to controls on minimal consent standards requiring merely expressing a treatment choice (S1) or making the reasonable treatment choice [S2], but significantly below controls on the three clinically relevant standards of appreciation (S3), reasoning (S4), and understanding (S5). In turn, the MCI group performed significantly better than the mild AD group on [S2], S4, and S5. Regarding capacity status, patients with MCI showed a progressive pattern of capacity compromise (marginally capable and incapable outcomes) related to stringency of consent standard.

CONCLUSIONS

Patients with amnestic mild cognitive impairment (MCI) demonstrate significant impairments on clinically relevant abilities associated with capacity to consent to treatment. In obtaining informed consent, clinicians and researchers working with patients with MCI must consider the likelihood that many of these patients may have impairments in consent capacity related to their amnestic disorder and related cognitive impairments.