Guideline for the management of chronic obstructive pulmonary disease--2011 update

OBJECTIVE

To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations.

KEY POINTS

(1) Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. (2) Spirometry is essential for the diagnosis and staging of COPD. (3) COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. (4) Oral corticosteroids are no longer recommended for maintenance treatment of COPD. (5) A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. (6) Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. (7) Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. (8) Acute exacerbations of COPD significantly affect morbidity, health care units and mortality. (9) Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. (10) COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes.

OPTIONS

Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease (GOLD), initiative, that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost.

OUTCOME

Holistic management utilising pharmacological and nonpharmacological options are put in perspective.

EVIDENCE

Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. BENEFITS, HARMS AND COSTS. The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction.

RECOMMENDATIONS

These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery.

VALIDATION

The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. GUIDELINE SPONSOR: The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith-Kline.

What goes down must come up: role of the posteromedial cortices in encoding and retrieval

The hypothesis that the neural network supporting successful episodic memory retrieval overlaps with the regions involved in episodic encoding has garnered much interest; however, the role of the posteromedial regions remains to be fully elucidated. Functional magnetic resonance imaging (fMRI) studies during successful encoding typically demonstrate deactivation of posteromedial cortices, whereas successful retrieval of previously encoded information has been associated with activation of these regions. Here, we performed an event-related fMRI experiment during an associative face-name encoding and retrieval task to investigate the topography and functional relationship of the brain regions involved in successful memory processes. A conjunction analysis of novel encoding and subsequent successful retrieval of names revealed an anatomical overlap in bilateral posteromedial cortices. In this region, a significant negative correlation was found: Greater deactivation during encoding was related to greater activation during successful retrieval. In contrast, the hippocampus and prefrontal cortex demonstrated positive activation during both encoding and retrieval. Our results provide further evidence that posteromedial regions constitute critical nodes in the large-scale cortical network subserving episodic memory. These results are discussed in relation to the default mode hypothesis, the involvement of posteromedial cortices in successful memory formation and retention, as well as potential implications for aging and neurodegenerative disease.

[Postoperative analgesia following trapeziectomy with continuous intra-articular infusion of ropivacaïne versus continuous perineural infusion. A prospective randomised study]

A prospective randomised study on 46 patients was performed to evaluate postoperative analgesia after trapezectomy. We compare the efficacy of an in situ catheter 777 (ISC) positioned by the surgeon in the space of the trapezectomy (26 patients) with an axilliary perineural catheter (APC) positioned preoperatively by the anaesthetist (20 patients). The patients were followed-up postoperatively for 48 hours and assessed at 3, 7, 24 and 48 hours, recording pain (VAS), consumption of intravenous rescue analgesia and recovery of sensory and motor function.

RESULTS

The mean time to site the ISC was 1 min 30 versus 16 min the APC group. The mean pain scores were: in the ISC group consistently below 2 for the entire postoperative 48 hours. Seven patients (29%) required supplemental analgesia (16 doses). Two patients failed (7.7%) to achieve adequate postoperative analgesia; they were the only patients in whom the surgeon had sited a drain, probably implying a siphoning off of the local anaesthetic solution. In the APC group also less than 2, and rescue analgesia was required by seven patients (35%) (40 doses). In four patients (20%) the pain score remained greater than 4 throughout the study period implying failure of the perineural catheter. There was a more rapid and complete recovery of both sensory and motor function in the group treated with in situ catheters during the study period. There were no haematomata or infections in the tow groups.

CONCLUSION

The in situ catheter provided at least as good postoperative analgesia while requiring considerably less time and expertise to site. There was also more rapid recovery of motor and sensory function in patients treated with in situ catheters.

An unusual cause of pelvic pain: struma ovarii

A 22 year old female patient presented with a three month history of pelvic discomfort and dysmenorrhoea. A pelvic MRI demonstrated a large mass measuring 10 x 6 cm in size. On T1 and T2 weighted images the mass was noted to be predominantly cystic. The mass also contained peripheral solid components as well as a large fat fluid level. Following excision, histological examination revealed a lesion with mature teratomatous elements but with a significant component (> 50%) being composed of mature thyroid tissue. A 2cm area within the lesion had the morphological pattern of a classical papillary thyroid carcinoma. A diagnosis of struma ovarii was made. Struma ovarii is a rare ovarian neoplasm generally arising in a teratoma and accounts for less than 1% all ovarian neoplasms. Here we present the above case of struma ovarii in a young patient and discuss the radiological characteristics of the disease.

Deep frontal and periventricular age related white matter changes but not basal ganglia and infratentorial hyperintensities are associated with falls: cross sectional results from the LADIS study

BACKGROUND

Global age related white matter changes (ARWMC) are associated with progressive gait disturbances and falls, hypothesised to result from interruptions of cortico-subcortical circuits controlling balance, posture and locomotion.

METHODS

The location of ARWMC in a large cohort of elderly non-disabled individuals with reported falls was analysed, using the cross sectional data of the Leukoaraiosis and Disability (LADIS) study. Detailed anatomical distributions of ARWMC assessed by MRI studies were analysed with respect to falls and balance performance.

RESULTS

The severity of global ARWMC was significantly associated with a history of falls in the year prior to study inclusion (22.2% in the mild, 31.6% in the moderate and 37.3% in the severe ARWMC group according to the Fazekas scale; p = 0.002). Analysing the anatomical distribution of ARWMC, using the semiquantitative Scheltens scale, in multivariate analysis, periventricular (p = 0.006) and frontal deep (p = 0.033) ARWMC were independently associated with falls. Furthermore, logistic regression identified frontal deep (p = 0.003) ARWMC, but not basal ganglia and infratentorial hyperintensities, as significantly associated with balance disturbances.

CONCLUSION

The association of frontal and periventricular ARWMC with falls supports the hypothesis that interruption of frontal subcortical motor circuits lead to balance disturbances and hence to an increased risk for falls in ARWMC.

Hypersensitivity reactions to neuromuscular blocking agents

Neuromuscular blocking agents are the leading drugs responsible for immediate hypersensitivity reactions during anaesthesia. Most hypersensitivity reactions represent IgE-mediated allergic reactions. Their incidence is estimated to be between 1 in 3,000 to 1 in 110,000 general anaesthetics. However striking variations have been reported among countries. The mechanism of sensitisation seems to implicate the presence of a substituted ammonium ion in the molecule. Due to lack of exposure prior to the reaction in a large number of reactors, it has been hypothesised that sensitisation may involve other, as yet undefined, substituted (quaternary and tertiary) ammonium ion containing compounds such as pholcodine, present in the environment of the patient. This hypothesis is still under investigation. The mechanism of non-IgE mediated hypersensitivity reactions is less well known. Identified mechanisms correspond to direct histamine release or interactions with muscarinic and nicotinic receptors. Allergic reactions cannot be clinically distinguished from non-IgE-mediated reactions. Therefore, any suspected hypersensitivity reaction must be investigated using combined pre and postoperative testing. Because of the frequent but not systematic cross-reactivity observed with muscle relaxants, every available neuromuscular blocking agent should be tested, using intradermal tests to confirm the responsibility of the suspected drug which should be definitely excluded. Cross-sensitivity investigation will also try to identify the safety of drugs that can be potentially used in future anaesthesia. The determination of basophil activation investigations using direct leukocyte histamine release test or flow cytometry would be of particular interest to investigate cross sensitisation in complement to skin tests. There is no demonstrated evidence supporting systematic pre-operative screening in the general population at this time. However, since no specific treatment has been shown to reliably prevent anaphylaxis, allergy assessment must be performed in all high-risk patients. In view of the relative complexity of allergy investigation, and of the differences between countries, an active policy to identify patients at risk and to provide any necessary support from expert advice to anaesthetists and allergologists through the constitution of allergo-anaesthesia centres in every country should be promoted.

Comprehensive ultrasound assessment of complications post-liver transplantation

Human liver transplantation for end-stage liver disease was first performed in 1963. Refinements in surgical technique and new immunosuppressive regimens have improved outcomes. Today, transplant patients have a 5-year survival rate of approximately 75%. Nevertheless, significant complications still occur. Ultrasonography (US), is the initial imaging modality of choice allowing bedside assessment for detection and follow-up of early and delayed graft complications, and facilitating interventional procedures. This review outlines the role of ultrasound in post-transplantation assessment.

A novel process for the removal of aniline from wastewaters

The aim of this research was to develop a solid regenerable catalytic adsorbent capable of removing aniline from aqueous solutions. A H-Beta zeolite was first loaded with copper in an ion-exchange process to enhance its catalytic activity. Experimental results indicated an aniline adsorption level of approximately 106-114 mg g(-1) for each of the unmodified H-Beta, the 0.5% (w/w) Cu-Beta or the 1.4 % (w/w) Cu-Beta zeolites. The adsorption processes followed the Langmuir model and the level of aniline adsorbed was largely unaffected by a change in temperature. Assessment of the aqueous stability of the exchanged copper on the Beta zeolites indicated minimum copper leaching in the range pH 5-11 thus providing a stable working pH range for both the 0.5% (w/w) and 1.4% (w/w) Cu-Beta adsorbent materials. Catalytic oxidation studies on the adsorbed aniline indicated that the presence of copper in the zeolites significantly enhanced the degradation of aniline to predominantly carbon dioxide, water and nitrogen. Five successive adsorption/catalytic oxidation cycles did not diminish the aniline adsorption capacity of the copper loaded zeolites but there was a small loss in the efficacy of the catalytic oxidation of the adsorbed aniline by the end of the 5th cycle.

Does online submission of manuscripts improve efficiency?

AIMS

The purpose of this study online is to evaluate whether online submission of papers to a peer reviewed journal is more efficient than hard copy submission.

MATERIALS AND METHODS

A retrospective study covering a 12-month period was performed. With the help of the editorial office of a selected radiologic journal: Clinical Radiology, we retrospectively audited the Clinical Radiology issues of accepted papers from July 2003 to July 2004 to compare articles that were submitted and evaluated on line against those that were submitted and evaluated by hard copy. Some manuscripts were submitted on line and evaluated by hard copy and were therefore included as a third data set. Manuscripts were sub-divided under the headings: review articles, pictorial reviews, original papers, technical reports and case reports. Data was tabulated in relation to the length of time between submission and acceptance. Both total, as well as average times under each individual heading were calculated. Data sets were then compared to assess if there was any time efficiency benefit between online and hard copy submission.

RESULTS

Data on 155 papers submitted and accepted to Clinical Radiology was obtained. The average number of days that it took an article that was submitted and reviewed online was 108.9 days. An article submitted online with paper review took on average 147.2 days and those submitted solely by paper took on average 149.8. When this data was further subdivided, for the online submission and review group, the average number of days for a review article to be submitted and reviewed took 91.9 days, for a pictorial review article, it took 69.6 days and it took 123.6 days for an original paper. With respect to online submission with paper review, a review article took 84 days, a pictorial review article took 120 days and an original paper took 145.4 days. With respect to paper submission and review, it took for 165.1 days for a review article, 147.8 days for a pictorial review article and 143.1 days for an original paper.

CONCLUSION

Online manuscripts submission is more efficient than hard copy submission for all manuscript types.

Self-perceived memory impairment and cognitive performance in an elderly independent population with age-related white matter changes

OBJECTIVES

To determine whether self-perceived memory impairment is associated with the severity of white matter changes (WMC) and is related to cognitive impairment.

METHODS

Data were drawn from the multinational Leukoaraiosis and Disability Study (LADIS), which investigates the impact of WMC on global functioning. WMC severity was rated using the Fazekas scale. Medial temporal lobe atrophy (MTA) was scored visually and mean values were calculated. The neuropsychological battery consisted of the Mini-Mental State Examination, a modified version of the VADAS-Cog, Trail making and Stroop tests. A question about self-perceived memory impairment was used as a measure for presence of memory complaints. Cognitive performance was analysed test-by-test and in three main domains: memory, executive functions and speed/motor control. The Geriatric Depression Scale (GDS) was used as a measure of depressive symptoms.

RESULTS

Six hundred and thirty-eight subjects were included in this study. No association was found between memory complaints and the severity of WMC. Subjects with memory complaints (n = 399) had a higher GDS score [t((637)) = -7.15; p<0.02] and performed worse on almost all cognitive tests and on the three cognitive domains. Multiple linear regression showed that the worse performance on the memory domain was associated with memory complaints independently of depressive symptoms, WMC severity and MTA (R(2) = 0.183; F = 17.09, beta = -0.126; p<0.05).

CONCLUSION

In a sample of non-disabled elderly subjects with WMC, self-perceived memory impairment is significantly associated with objective memory impairment independently of the WMC severity, depressive symptoms and MTA.

Imaging of horseshoe kidneys and their complications

Horseshoe kidney is the most common renal fusion anomaly and the patients are prone to a variety of complications, such as stone disease, pelviureteric junction (PUJ) obstruction, trauma, infections and tumours. As result of the abnormal anatomy of a horseshoe kidney, imaging and treatment pathways vary substantially from the normal kidney. In this review, we describe the role of modern imaging in depicting horseshoe kidneys and their complications, in tandem with the role the interventional radiologist plays in treating these patients.

A case of back pain associated with neurology in a young man

BACKGROUND

We present the case of a 14-year-old with a 3-month history of back pain, who on presentation, was demonstrated to have neurological signs.

METHOD

Investigation with radiographs and subsequent magnetic resonance imaging was performed, which demonstrated an expansile lesion in the tenth thoracic vertebra with posterior extension causing spinal cord compression. This was treated with surgical resection and spinal cord decompression.

RESULTS

Diagnosis of aneurysmal bone cyst was made following histopathological examination of the resected lesion.

CONCLUSION

Back pain in childhood is a significant and often sinister symptom, which requires careful evaluation.

Imaging of adenomyomatosis of the gall bladder

Adenomyomatosis is a relatively common abnormality of the gall bladder, with a reported incidence of between 2.8 and 5%. Although mainly confined to the adult study group, a number of cases have been reported in the paediatric study group. It is characterized pathologically by excessive proliferation of the surface epithelium and hypertrophy of the muscularis propria of the gall bladder wall, with invagination of the mucosa into the thickened muscularis forming the so-called 'Rokitansky-Aschoff' sinuses. The condition is usually asymptomatic and is often diagnosed as an incidental finding on abdominal imaging. The radiological diagnosis is largely dependent on the visualization of the characteristic Rokitansky-Aschoff sinuses. As the condition is usually asymptomatic, the importance of making a correct diagnosis is to prevent misinterpretation of other gall bladder conditions such as gall bladder cancer, leading to incorrect treatment. In the past, oral cholecystography was the main imaging method used to make this diagnosis. In most institutions, oral cholecystography is no longer carried out, and the diagnosis is now more commonly seen on cross-sectional imaging. In this review article, we describe the manifestations of adenomyomatosis on the various imaging methods, with an emphasis on more modern techniques such as magnetic resonance cholangiopancreatography. A brief section on oral cholecystography to aid readers familiar with this technique in understanding the comparable imaging features on more modern imaging techniques is included.

Association of gait and balance disorders with age-related white matter changes: the LADIS study

OBJECTIVE

In the Leukoaraiosis and Disability (LADIS) Study, 11 European centers are evaluating the role of age-related white matter changes (ARWMC) as an independent determinant of the transition to disability in the elderly (65 to 84 years). We aimed at determining the influence of ARWMC on different objective measures of gait and balance.

METHODS

Six hundred thirty-nine nondisabled individuals were prospectively enrolled and are being followed-up for 3 years. Subjects are graded in three standardized categories of ARWMC (mild, moderate, and severe) according to central MRI reading. Quantitative tests of gait and balance include the Short Physical Performance Battery (SPPB; range: 0 [poor] to 12 [normal]), a timed 8-m walk, and a timed single leg stance test.

RESULTS

In cross-sectional analysis, deficiencies in gait and balance performance were correlated with the severity of ARWMC (SPPB: 10.2 +/- 2.1 in the mild, 9.9 +/- 2.0 in the moderate, 8.9 +/- 2.6 in the severe group; p < 0.001). Walking speed correlated with the severity of ARWMC (1.24 +/- 0.28 m/second in the mild, 1.18 +/- 0.32 m/second in the moderate, and 1.09 +/- 0.31 m/second in the severe group; p < 0.001). Balance was best in individuals with mild ARWMC (single leg stance time: 18.9 +/- 10.8 seconds) compared with moderate and severe ARWMC (16.4 +/- 10.8 and 13.6 +/- 11.2 seconds) (p < 0.001). Physically inactive individuals had a higher risk of a pathologic SPPB score (moderate vs mild ARWMC: odds ratio 1.60, 95% CI 1.02 to 2.52; severe vs mild ARWMC: odds ratio 1.75, 95% CI 1.09 to 2.80).

CONCLUSIONS

Our findings support a strong association between the severity of age-related white matter changes and the severity of gait and motor compromise. Physical activity might have the potential to reduce the risk of limitations in mobility.

Calvarial tuberculosis: an unusual presentation (2007: 8b)

We describe a case of calvarial tuberculosis with an associated extra-dural collection. This presentation has rarely been reported in the literature and the magnetic resonance imaging features are not well documented.

Hypoalbuminaemia and colonic polyps: a case of protein-losing enteropathy with cap polyposis?

A 69-year-old woman was admitted in September 2005 dehydrated and unwell. She had a 6-month history of constipation, poor appetite and weight loss, and was hypoalbuminaemic (21 g/litre). She had initially been referred for colonoscopy in March to exclude colonic malignancy. Multiple pedunculated polyps up to the splenic flexure were seen, with histology felt to be consistent with hyperplastic polyps and mild inflammation. Her symptoms persisted, and by August she had lost 3 stone in weight. She started to experience loose stools, and repeat colonoscopy was planned. However, the bowel preparation made her feel unwell. She couldn't walk, and so presented to the acute medical take.

The patient looked pale and dehydrated. Her chest was clear, with a diffusely tender abdomen. Bowel sounds were present, and there were no palpable masses. Bloods showed a corrected calcium of 1.58 mmol/litre. Fluid resuscitation and calcium replacement was started. A malignant process was queried. Liver function tests showed a low albumin of 21 g/litre but were otherwise unremarkable. A computed tomography scan of the abdomen and chest were normal. A gastroscopy showed mild oesophagitis with Candida in the mid and lower oesophagus, gastritis in the antrum of the stomach with heavy Helicobacter pylori growth, and a normal duodenum. Biopsies showed no evidence of coeliac disease or giardia.

The patient's albumin fell to 8 g/litre. A 24-hour urine protein collection was 0.46 g, excluding nephrotic syndrome. Nasogastric feeding was commenced.

Gut hormones showed a modestly elevated chromogranin A (164 pmol/litre) and gastrin (307 pmol/ litre) but were not diagnostic of a neuroendocrine tumour. Amyloid was queried and the original colonic biopsies re-examined. This was not found, but cap polyposis was suggested.

The patient failed to improve and died 15 days after admission. Post mortem found the distal large bowel to contain multiple dark sessile polyps, looking like slugs, on exaggerated mucosal folds (Figure 1). The histological findings comprised elongated, tortorous and distended crypts, with evidence of inflammation and a 'cap' of granulation tissue, confirming cap polyposis. In addition the patient had a right haemothorax. This was caused by a dissection in the pulmonary artery, with evidence of atheroma identified. The right ventricle was hypertrophic, with the lungs showing multiple haemorrhagic infarcts. These changes suggested pulmonary hypertension. Whether this was related to the cap polyposis was unclear. A reasonable explanation is that the patient had showered off pulmonary emboli from a deep vein thrombosis (DVT) for some time, secondary to immobility associated with her poor state of health. This was supported by a right calf DVT identified at post mortem. The dissection of the pulmonary artery was probably secondary to the low protein state and pulmonary artery hypertension.

Vesicoureteric reflux in the adult

Vesicoureteric reflux (VUR) is a well-recognized entity in the paediatric population, but is not well described or understood in the adult population. This is partly explained by the fact that its incidence declines with advancing age. Its diagnosis is, however, still important, with VUR accounting for at least 10% of adult patients with end-stage renal disease. With early detection and careful management, the secondary complications of VUR such as renal failure can be prevented. Imaging plays a major role in the detection and evaluation of VUR in the adult patient. Conventional techniques such as micturating cystourethrograms have now been supplemented by cross-sectional imaging with CT and MRI. In this review article, we comprehensively review the up to date status of imaging the adult patient with VUR and discuss important subgroups of patients such as pregnant and transplant patients.

Fluid restriction during running increases GI permeability

The purpose of this study was to determine gastrointestinal (GI) permeability during prolonged treadmill running (60 min at 70 % V.O2max) with and without fluid intake (3 ml/kg body mass/10 min). Twenty runners (11 males, 9 females; age = 22 +/- 3 (SD) yrs; mean V.O2max = 55.7 +/- 5.0 ml/kg/min) completed four experiments: 1) rest, 2) running with no fluid (NF), 3) running with ingestion of a 4 % glucose solution (GLU), and 4) running with ingestion of a water placebo (PLA). To determine GI permeability, subjects also drank a solution containing 5 g sucrose (S), 5 g lactulose (L), and 2 g rhamnose (R) immediately prior to each trial. Gastroduodenal permeability was determined by urinary S excretion, while small intestinal permeability was determined by the L/R excretion ratio. Percent body mass loss (i.e., dehydration) was negligible during rest, GLU and PLA, while NF resulted in a 1.5 % loss of body mass (p < 0.05). Gastroduodenal and intestinal permeability were significantly (p < 0.008) increased in NF compared to rest. There were no other differences in GI permeability. These results indicate that fluid restriction during 1 h of steady-state running increases GI permeability above resting levels.

Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement

AIM

To assess the relationship between the severity of full-thickness supraspinatus tendon tears and the development of subcoracoid impingement.

MATERIALS AND METHODS

Fifty-one magnetic resonance imaging (MRI) shoulder examination reports with full-thickness supraspinatus tears were retrospectively identified and reviewed by two dedicated musculoskeletal radiologists. The appearances of the rotator cuff muscles, biceps tendon and the lesser tubercle were recorded. The acromio-humeral distance and the axial coraco-humeral distance were measured. The data were recorded and analysed electronically.

RESULTS

The kappa values for inter-observer agreement were: 0.91 for acromio-humeral distance and 0.85 for coraco-humeral distance measurements. Twenty-six patients had significant retraction of the supraspinatus tendon, 85% (22 cases) of this group had imaging evidence of tear or tendonopathy of the subscapularis tendon. Twenty-five patients had no significant retraction of the supraspinatus, 56% (14 cases) of this group had imaging evidence of a subscapularis tear or tendonopathy. The acromio-humeral distance was significantly less in patients with supraspinatus tears and retraction (p<0.05). The subscapularis tendon was significantly more likely to be abnormal if the supraspinatus was retracted than if no retraction was present (p<0.05). There were no significant differences in coraco-humeral distances between the groups.

CONCLUSION

Subscapularis tendon signal and structural changes are frequently associated with full-thickness supraspinatus tendon tears, particularly if the supraspinatus is significantly retracted. In this static MRI series, the data do not support the occurrence of classical subcoracoid impingement as an aetiology; however, they may support the possibility of a dynamic mechanism, to which future studies could be directed.

[Pertussis: incidence, symptoms and costs]

BACKGROUND AND OBJECTIVE

A prospective sentinel study into the population-based incidence of pertussis in adults was done between 2001 and 2004 in Rostock (former East Germany) and Krefeld (former West Germany).

PATIENTS AND METHODS

971 outpatients, who consulted general practitioners or internists, were included. Clinical inclusion criteria were coughing for one week or more and no chronic respiratory diseases. Bordetella infection was diagnosed by PCR on nasopharyngeal swabs and ELISA for serology (IgG-anti-PT, IgA-anti-PT, IgG-anti-FHA, IgA-anti-FHA).

RESULTS

We found a total of 97 cases of pertussis in this cohort. The main symptom was coughing for a median of 7-8 weeks. Population-based incidence was estimated in Krefeld at 169 cases/100000 population per year, and in Rostock at 160/100000 per year. Resource use was 120 EUR of direct medical cost and 434 euro of indirect medical cost, not including hospitalization in this study.

CONCLUSIONS

Pertussis is a frequent cause of longer lasting cough in German adults, and it causes significant morbidity and costs.

An unusual case of elevated liver enzymes (2006: 10b)

HELLP syndrome is a form of severe pre-eclampsia with multisystem involvement. Laboratory markers include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). We present a patient to our institution with HELLP syndrome complicated by liver necrosis. The patient underwent urgent Caesarian section prior to transfer.

Differences in neuropathologic characteristics across the Lewy body dementia spectrum

BACKGROUND

The objective of this comparative neuropathologic study was to determine the extent to which dementia with Lewy bodies (DLB) and Parkinson disease dementia (PDD) are distinct entities or part of a continuum with respect to the duration of parkinsonism.

METHODS

We evaluated the relationship between cortical alpha-synuclein pathology, plaques (Consortium to Establish a Registry for Alzheimer's Disease [CERAD]), tangles (Braak staging), and cholinergic deficits (choline acetyltransferase in temporal cortex) in 57 prospectively assessed patients (29 DLB, 28 PDD), confirmed at autopsy. The PDD group was divided according to the median duration of parkinsonism prior to dementia.

RESULTS

There was an association between longer duration of parkinsonism prior to dementia and less severe cortical alpha-synuclein pathology (chi(2) 10.4, df 2, p = 0.006) and lower CERAD plaque scores (chi(2) 26.6, df 9, p = 0.002), but not Braak staging. These findings were confirmed in a further correlation analysis, which also identified an unexpected correlation between more pronounced cortical cholinergic deficits and longer duration of parkinsonism prior to dementia (R = -0.37, p = 0.04).

CONCLUSION

While there is a clear relationship between the duration of Parkinson disease prior to the onset of dementia and key neuropathologic and neurochemical characteristics, there is a gradation of these differences across the dementia with Lewy bodies/Parkinson disease dementia spectrum and the findings do not support an arbitrary cut-off between the two disorders.