Paraneoplastic movement disorders

Paraneoplastic movement disorders are diverse autoimmune neurological illnesses occurring in the context of systemic cancer, either in isolation or as part of a multifocal neurological disease. Movement phenomena may be ataxic, hypokinetic (parkinsonian), or hyperkinetic (myoclonus, chorea, or other dyskinetic disorders). Some disorders mimic neurodegenerative or hereditary illnesses. The subacute onset and coexisting nonclassic features of paraneoplastic disorders aid distinction. Paraneoplastic autoantibodies provide further information regarding differentiating cancer association, disease course, and treatment responses. A woman with cerebellar ataxia could have metabotropic glutamate receptor 1 autoimmunity, in the setting of Hodgkin lymphoma, a mild neurological phenotype and response to immunotherapy. A different woman, also with cerebellar ataxia, could have Purkinje cytoplasmic antibody type 1 (anti-Yo), accompanying ovarian adenocarcinoma, a rapidly progressive phenotype and persistent disabling deficits despite immune therapy. The list of antibody biomarkers is growing year-on-year, each with its own ideal specimen type for detection (serum or CSF), accompanying neurological manifestations, cancer association, treatment response, and prognosis. Therefore, a profile-based approach to screening both serum and CSF is recommended. Immune therapy trials are generally undertaken, and include one or more of corticosteroids, IVIg, plasma exchange, rituximab, or cyclophosphamide. Symptomatic therapies can also be employed for hyperkinetic disorders.

Multitrial free recall for evaluating memory

OBJECTIVE

Much of our knowledge concerning the neural basis of human memory derives from lab-based verbal recall tasks. Outside of the lab, clinicians use validated and normed neuropsychological tests to assess patients' memory function and to evaluate clinical interventions. Here we sought to establish the clinical validity of examining memory through multitrial free recall of semantically organized and unrelated word lists.

METHOD

We compare memory performance in multitrial free recall tasks with the Rey Auditory Verbal Learning Test and the California Verbal Learning Test, two common neuropsychological tests aimed at evaluating memory function in clinical settings. We compare predictive validity between the tasks by evaluating deficits in a patient sample and examining age-related declines in memory. We additionally compare test-retest reliability, establish convergent validity, and show the emergence of common recall dynamics between the tasks.

RESULTS

We demonstrate that both laboratory free recall tasks have better predictive validity and test-retest reliability than the established neuropsychological tests. We further show that all tasks have good convergent validity and reveal core memory processes, including temporal and semantic organization. However, we also demonstrate the benefits of repeated trials for evaluating the dynamics of memory search and their neuropsychological sequelae.

CONCLUSIONS

These results provide evidence for the clinical validity of lab-based multitrial free recall tasks and highlight their psychometric benefits over neuropsychological measures. Based on these results, we discuss the need to bridge the gap between clinical understanding of putative mechanisms underlying memory disorders and neuroscientific findings obtained using lab-based free recall tasks. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Novel imaging techniques using 18 F-florbetapir PET/MRI can guide fascicular nerve biopsy in amyloid multiple mononeuropathy

BACKGROUND

Multiple mononeuropathy is a rare presentation of primary (AL) amyloidosis and nerve biopsy is usually needed for diagnosis. Conventional imaging is useful to identify proximal nerve involvement but may be inadequate. We report a patient with multiple mononeuropathy whose presentation was suggestive of AL amyloid neuropathy and in whom repeated tissue biopsies were negative for amyloid (including two sensory nerves and one muscle).

METHODS

The patient underwent magnetic resonance imaging (MRI) and whole body ¹⁸ F-florbetapir positron emission tomography (PET)/MRI.

RESULTS

Whole body ¹⁸ F-florbetapir PET/MRI revealed abnormal low-level florbetapir uptake in the right proximal tibial and peroneal nerves, which provided a target for a sciatic bifurcation fascicular nerve biopsy that was diagnostic of AL amyloidosis.

CONCLUSIONS

¹⁸ F-florbetapir PET/MRI imaging is a promising diagnostic tool for patients with suspected peripheral nerve amyloidosis (including multiple mononeuropathy) in whom conventional imaging and nerve and muscle biopsies miss the pathology.

Are on-the-day group and save samples required for elective shoulder, hip and knee arthroplasties?

INTRODUCTION

Historically, patients undergoing an elective hip, knee or shoulder arthroplasty regularly required blood transfusions. Improved surgical techniques and perioperative optimisation have significantly decreased the requirement for blood transfusions. Currently, our patients have two group and save samples taken: one six weeks preoperatively and one on admission. This study aims to determine whether a second group and save is required prior to primary elective hip, knee or shoulder arthroplasty.

METHODS

All cases of elective arthroplasty from a single centre were retrospectively analysed over a 16-month period. Each case was reviewed to determine those who had a group and save at preassessment, group and save at the time of the operation and the timing and number of blood products transfused.

RESULTS

A total of 711 elective arthroplasty procedures were completed with 48 patients requiring a transfusion during their admission. 9.9% of hip arthroplasty patients, 3.8% of knee arthroplasty patients and 4.9% of shoulder arthroplasty patients required a transfusion. The majority of the transfusions occurred at least 24 hours postoperatively with 0.84% of patients requiring an intraoperative transfusion.

DISCUSSION

The vast majority of transfusions were delivered more than 24 hours following the procedure, demonstrating that routinely cross-matched blood products are superfluous to requirements. It is our suggestion that a formal group and save be completed only if the need for a blood transfusion is formally established, leading to a significant cost saving, a reduction in clinical work load and patients having to undergo fewer procedures.

Pharmacokinetics and safety of subcutaneous immune globulin (human), 10% caprylate/chromatography purified in patients with primary immunodeficiency disease

Subcutaneous administration of intravenous immunoglobulin G (IgG) preparations provides an additional level of patient convenience and more options for patients with poor venous access or a history of intravenous IgG reactions. An open-label, pharmacokinetic trial (n = 32) determined the non-inferiority of the subcutaneous versus intravenous route of 10% caprylate/chromatography purified human immune globulin intravenous (IGIV-C; Gamunex®) administration by comparing the steady-state area under the concentration-versus-time curve (AUC) of total plasma IgG in patients with primary immunodeficiency disease. Patients on stable IGIV-C received two intravenous infusions (administered 3 or 4 weeks apart). Seven to 10 days after the second intravenous infusion, all patients switched to a weekly infusion of subcutaneous IGIV-C, with the dose equal to 137% of the previous weekly equivalent intravenous dose, for up to 24 weeks. Samples for pharmacokinetic analysis were collected during steady state for intravenous and subcutaneous IGIV-C treatments. The AUC(0-) τ geometric least-squares mean ratio was 0·89 (90% confidence interval, 0·86-0·92) and met the criteria for non-inferiority. The overall mean steady-state trough concentration of plasma total IgG with subcutaneous IGIV-C was 11·4 mg/ml, 18·8% higher than intravenous IGIV-C (9·6 mg/ml). Subcutaneous IGIV-C was safe and well tolerated. Subcutaneous IGIV-C infusion-site reactions were generally mild/moderate and the incidence decreased over time. No serious bacterial infections were reported. Weekly subcutaneous IGIV-C infusion using 137% of the weekly equivalent intravenous immunoglobulin dose provides an AUC comparable to intravenous administration, thus allowing patients to maintain the same IgG preparation/formulation if switching between intravenous and subcutaneous infusions.

Driving resumption and its predictors after stroke

BACKGROUND AND PURPOSE

Despite the prevalence of ischemic stroke, little is known regarding driving resumption and its determinants after stroke. This study documents driving resumption poststroke and describes the relationship between specific variables and driving resumption.

METHOD

Between May 2001 and January 2002, 110 consecutive patients admitted to Hartford Hospital with acute ischemic stroke, who had driven during the month before admission, were enrolled in this cohort study. Stroke outcome measures including the NIH Stroke Scale, Barthel Index, Short Form (SF-12), COOPS social support scale, and an original questionnaire were administered. Patients were followed up at three and six months to establish poststroke driving status. The relationship between driving resumption and the predictor variables was determined using correlations (point-biserial and phi coefficients) and forward multiple logistic regression.

RESULTS

Forty (50%) of the surveyed patients resumed driving within one month of their strokes. The best logistic regression model (R2 = 0.391) for predicting resumption of driving after stroke included the variables prestroke driving frequency (OR = 7.74 [2.47-24.3]), poststroke Barthel Index score (OR = 1.16 [1.06-1.27]), and marital status (OR = 3.55 [1.28-9.83]).

CONCLUSION

Resumption of driving is early after mild strokes. Factors other than the specific consequences of the stroke contribute to the prediction of driving resumption. While factors such as prestroke driving frequency, functional independence and marital status should not be used as a sanction for driving resumption, they offer insights to individuals who are likely to resume driving early after an ischemic stroke.

Using telemedicine to avoid transfer of rural emergency department patients

Access to emergency treatment in rural areas can often mean the difference between life and death. Telemedicine technologies have the potential of providing earlier diagnosis and intervention, of saving lives and of avoiding unnecessary transfers from rural hospital emergency departments to urban hospitals. This study examined the hypothetical impact of telemedicine services on patients served by the emergency departments of two rural Missouri hospitals and the potential financial impact on the affected hospitals. Of the 246 patients transferred to the hub hospital from the two facilities during 1996, 161 medical records (65.4 percent) were analyzed. Using a conservative approach, only 12 of these cases were identified as potentially avoidable transfers with the use of telemedicine. Of these 12, 5 were admitted to the hub hospital after transfer. In addition to this conservative estimate of avoidable transfers based on current availability of resources in the rural hospitals, two more aggressive scenarios were developed, based on an assumption of increased service availability in the rural hospitals. Economic multipliers were used to estimate the financial impacts on communities in each scenario. This evaluation study demonstrates the potential value of telemedicine use in rural emergency departments to patients, rural hospitals and rural communities.

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.

Hope and anxiety of individual family members of critically ill adults

This correlational study describes levels of hope and states of anxiety of individual family members of critically ill patients and investigates the relationship between hope and state of anxiety. Forty-four family members of critically ill patients participated in the study and revealed a high level of hope and a high level of anxiety within 72 hours of the patient's hospitalization, regardless of personal or situational characteristics. Hope and anxiety were not significantly related in this sample; themes of hope focused on past and present experiences, whereas anxiety centered on death of the loved one. Participants looked to the past, recalling happy times, and to the future, in relation to goals and potential. Family members acknowledged feeling secure, self-confident, and steady, and were able to make decisions because they were not confused about the situation. Nurses are challenged to inspire the family's hope and decrease their anxiety.

Cross-education of muscle strength is greater with stimulated than voluntary contractions

Cross-education enhances the performance of muscles not directly involved in the chronic conditioning of the muscles in a remote limb. Substantial cross-education occurs after training with eccentric contractions or with contractions evoked by electromyostimulation (EMS). Since during EMS and eccentric contractions, skin and muscle afferents are activated that have excitatory effects on contralateral homologous muscles, it was hypothesized that exercise training with stimulated vs. voluntary eccentric contractions would lead to greater cross-education. Thirty-two women were randomly assigned to a voluntary (Vol), an EMS, or remote EMS (rEMS) exercise group and performed 840 voluntary or stimulated eccentric contractions over 6 weeks. All subjects, including nonexercising controls (Con), were tested pre- and posttraining for maximal voluntary and stimulated isometric and eccentric quadriceps strength. Ipsilateral voluntary and stimulated forces increased in all groups. Changes in EMG activity paralleled those in voluntary force in each limb. No changes occurred in grip strength. The great contra- and ipsilateral strength gains after EMS training were most likely related to an additive effect of EMS and muscle lengthening.

Education for children with disabilities: the rationale for inclusion

OBJECTIVE

To discuss issues in the education of children with disabilities, particularly with respect to inclusion in mainstream classes.

METHODOLOGY

Review of the literature on education for children with disabilities, focusing on the inclusion versus segregation debate.

RESULTS

The literature provides no support for segregation and some support for the view that segregated children are disadvantaged. What seems to be important is the way the child is educated rather than where the education takes place. In addition, there are ethical, sociological, and legal arguments in favour of an inclusive educational system.

CONCLUSIONS

There are good arguments to encourage inclusive education for children with disabilities. In advising parents, doctors should focus on how rather than where the child with a disability should be educated.

The roles of the bacteriophage T4 r genes in lysis inhibition and fine-structure genetics: a new perspective

Seldom has the study of a set of genes contributed more to our understanding of molecular genetics than has the characterization of the rapid-lysis genes of bacteriophage T4. For example, T4 rII mutants were used to define gene structure and mutagen effects at the molecular level and to help unravel the genetic code. The large-plaque morphology of these mutants reflects a block in expressing lysis inhibition (LIN), the ability to delay lysis for several hours in response to sensing external related phages attacking the cell, which is a unique and highly adaptive attribute of the T4 family of phages. However, surprisingly little is known about the mechanism of LIN, or how the various r genes affect its expression. Here, we review the extensive old literature about the r genes and the lysis process and try to sort out the major players affecting lysis inhibition. We confirm that superinfection can induce lysis inhibition even while infected cells are lysing, suggesting that the signal response is virtually instantaneous and thus probably the result of post-translational regulation. We identify the rI gene as ORF tk.-2, based on sequence analysis of canonical rI mutants. The rI gene encodes a peptide of 97 amino acids (Mr = 11.1 kD; pI = 4.8) that probably is secreted into the periplasmic space. This gene is widely conserved among T-even phage. We then present a model for LIN, postulating that rI is largely responsible for regulating the gpt holin protein in response to superinfection. The evidence suggests that the rIIA and B genes are not directly involved in lysis inhibition; rather, when they are absent, an alternate pathway for lysis develops which depends on the presence of genes from any of several possible prophages and is not sensitive to lysis inhibition.

Normal forces and myofibrillar disruption after repeated eccentric exercise

To investigate the "rapid-adaptation" phenomenon, we examined force, neural, and morphological adaptations in 12 subjects who performed 100 eccentric contractions with the quadriceps muscle (bout 1) and repeated the same exercise after a 2-wk hiatus (bout 2). Two days after bout 1, quadriceps muscle strength and surface electromyographic (EMG) activity declined approximately 37 and 28%, respectively, in the control group (n = 6). At day 2 after bout 1, significant increases occurred in patellar tendon reflex amplitude (approximately 25%), muscle soreness (fivefold), and serum creatine kinase (220%), and 65 +/- 12% of the total number of pixels in the EMG indicated myofibrillar disruption. At day 7 after bout 1, all variables returned to normal. At day 2 after bout 2, no significant changes occurred in force, EMG, creatine kinase, or soreness, but reflex amplitude increased, and 23 +/- 4% of the total number of pixels in the EMG still indicated myofibrillar disruption. The results suggest that the rapid force recovery following eccentric exercise is mediated at least in part by neural factors and that this recovery may occur independently of cell disruption.

The importance of smoking education and preventative health strategies for people with intellectual disability

Tobacco smoking is a major health problem within our community. To date, little attention has been focused on determining the prevalence of smoking in people with disabilities or in developing appropriate strategies to assist them to stop smoking. Funding from the Victorian Health Promotion Foundation enabled the Developmental Disability Unit at Monash University, Box Hill, Victoria, Australia, to undertake a project investigating smoking in a population of people with intellectual disability. In the first part of the project, the smoking rate among a geographically defined group of people with mild intellectual disability was investigated. A smoking prevalence of 36% was found within the sample group, as compared to a prevalence of 26% within the general Victorian adult population. An association was found between the motivation to quite and the recall of advice to stop smoking. The second part of the project comprised the development and piloting of a smoking education course for people with intellectual disability. The pilot sample was small, but the results were encouraging. Fifty-five per cent of the group either quit smoking or cut down their intake significantly. Seventy-three per cent expressed a desire to stop smoking at the completion of the course, and all participants expressed an increased concern and knowledge about the effects of smoking on their health after completing the course.

Prevalence of adult diabetes in Ibadan, Nigeria

Within the framework of an international collaborative network, we measured the prevalence of diabetes mellitus in a traditional Yoruba community in the city of Ibadan, Nigeria. Using a random sampling technique we enrolled a community sample of 247 men and women. Fasting blood glucose (FBG) was measured at the community clinic from a fingerstick using the Companion2 Medisense blood glucose meter. The mean FBG was 4.7 mmol/L and 4.9 mmol/L for men and women, respectively. Using the 1985 WHO criteria, the prevalence of diabetes was 2.8%. There was no significant rise in FBG with age. Compared to the lowest quartile of the body mass index (BMI), there was about a 1.5 fold increased risk of developing elevated FBG. The test of trend between FBG and BMI was however not statistically significant. Despite a modest hypertension rate (22.3%), there was no significant difference in the FBG for hypertensives compared to normotensives. The findings of this study show that the prevalence of diabetes mellitus in this West African community remains low compared to nations in Western societies. However, in comparison to previous estimates from sub-Saharan Africa, the prevalence of adult onset diabetes seems to be on the increase.

Performance on the Purdue pegboard and finger tapping by schizophrenics after mellow and frenetic antecedent music

Effects of musical selections on motor performance have been inconsistent. Using a 3-factor within-subjects design [mellow music (4:4 time), frenetic music (2:8 time), and white noise conditions], each of 34 schizophrenic inpatients volunteered to perform the Purdue Pegboard and Finger Oscillation (Tapping) following 1-min. counterbalanced presentations of three types of music. Both pegboard and tapping performance were higher after frenetic music but unaffected by mellow music.

Outcome measures of a chronic pain program: a prospective statistical study

OBJECTIVE

To provide outcome data measuring objective and subjective variables of an individualized, multidisciplinary, comprehensive pain management program.

DESIGN

The study is a prospective evaluation of 50 consecutive patients who completed the pain management program. Objective measures were medication use and return to work. Subjective measures included self-reports of pain levels and completion of a Personal Concerns and Goals Assessment (PCGA) examining issues of lifestyle and emotional well-being. These measures were compared at program onset and completion by using appropriate statistical analyses.

RESULTS

Objective measures: Medication use by the study subjects decreased overall by 72% within all drug categories. Opioid use was eliminated. Regarding return to work, the study subjects increased their work hours by twofold overall. Of patients working fewer than 30 h per week at program onset, representing 62% of the study population, a fivefold return to work was observed. Subjective measures: Overall pain levels improved by 33%, with an 18 to 47% improvement in all descriptors (average pain levels on good or bad days, average number of good or bad days). Of the PCGA factors, patients improved 24 to 46% in all categories concerning lifestyle and emotional well-being. Correlative analysis of the data produced prognostic information as well as insights into chronic pain development.

CONCLUSIONS

This study of objective and subjective outcome measures demonstrates that a comprehensive program employing specific principles and methods produces an effective approach for the management of chronic pain. Patients disabled by chronic pain regain a quality of life that allows them to resume a functioning, productive role.

Fatigue effects on muscle excitability

Repeated isometric or shortening contractions of skeletal muscle cause muscle fatigue but several prior studies have reported an apparent absence of muscle fatigue when humans performed up to 70 lengthening contractions. We pursued the hypothesis that perhaps muscle excitability is a factor that aids force preservation with repeated eccentric actions. Soleus compound muscle action potential (M-wave) latency, peak-to-peak amplitude (PPA), duration, and area under the curve were examined in 12 subjects (mean age 24.3 y) over 4 testing days that included: no exercise, isometric exercise (neutral ankle angle), isokinetic (0.5 rad.s-1) concentric and eccentric exercise of the plantar flexors in the seated position on a Biodex dynamometer. Supramaximal shocks were delivered to the tibial nerve in the popliteal fossa at baseline (3 shocks, 1 min apart), during exercise (1 shock-after each of 5 bouts/10 contractions), and during 10-min recovery. From initial to final contractions, concentric, isometric, and eccentric fatigue was -32, -41 and + 2% (Condition by Trial Interaction, F2,22 = 25.1, p = 0.000). No changes occurred in latency or duration (p > 0.05), but PPA (Condition by Time interaction, F51,561 = 3.7, p = 0.000) increased during isometric and eccentric exercise and remained elevated during recovery. Area increased (F51,561 = 3.1, p = 0.000) significantly during all three exercise conditions and approximated baseline by minute 8 of recovery. It was concluded that although the potentiation of the action potential of individual muscle fibers seems to be the common mechanism underlying the increase in muscle excitability during plantar flexion exercise, it is possible that different factors could cause such a non-specific response.

Motor performance of schizophrenics after mellow and frenetic antecedent music

Previous research has yielded an inconclusive picture of the effects of music on motor performance. Using a 3-factor within-subjects design [mellow/4:4 time), frenetic/(2:8 time), and white noise music conditions], each of 19 schizophrenic inpatient volunteers performed a Purdue Pegboard and Finger Oscillation (Tapping) Test following 1-min. presentations of 3 types of music. Pegboard performance was higher after frenetic music but unaffected by mellow music; there was no effect on tapping.

What do the parents of children with disabilities want from their GP?

When a family come to the GP they bring with them their hopes and expectations for that consultation. Because the author wears two hats, those of 'mother of a child with a disability' and 'doctor', other parents often discuss with her their experiences with the medical profession. This article summarises the features of a medical consultation that are most valued by parents.

'Two hats can be hard to wear'

I wear my two hats proudly now, that of a mother of a child with a disability and that of a doctor. My 'mother hat' is not removable. I have tried to separate myself from it at times, but that is too painful--it is a part of me. My 'doctor hat' is rather like a smart balaclava. It is appropriate and useful in specific situations. It can be pulled over my eyes to hide how I feel and, at times, offers some protection. But it can also obscure my vision and sometimes causes me to stumble over obstacles I may otherwise have successfully negotiated.

Risk of late stroke and survival following carotid endarterectomy procedures for symptomatic patients

The long-term outcome following carotid endarterectomy for neurological symptoms was analyzed using a retrospective life-table approach in 212 patients who had undergone 243 endarterectomy procedures. The postoperative follow-up period averaged 38.9 +/- 2.1 months (mean +/- standard error of the mean). The endpoints of stroke and death were evaluated in these patients. Patient groups with the preoperative symptoms of amaurosis fugax, transient ischemic attack, and prior recovered stroke were similar in terms of life-table outcome over the follow-up period. Sixty-two percent of symptomatic patients were alive and free of stroke at 5 years. The late risk of stroke (after 30 days postoperatively) averaged 1.7% per year based on a linear approximation to the hazard at each life-table interval (1.3% per year for ipsilateral stroke). The trend of late stroke risk was clearly downward, however, and could be fitted more accurately by an exponential decay function with a half-life of 33 months. Thus, the risk of stroke following carotid endarterectomy for neurological symptoms was highest in the perioperative period, slowly declined with time, and occurred predominantly ipsilateral to the procedure. The definition of a prospective medical control group remains crucial for a critical analysis of treatment modalities following the onset of premonitory neurological symptoms. In the absence of an adequate control group for this series, the calculated perioperative and postoperative stroke risk from this study was compared to data obtained from the literature on stroke risk in medically treated symptomatic patients. This uncontrolled comparison of treatment modalities suggests the combined perioperative and postoperative stroke risk associated with carotid endarterectomy to be modestly improved over medical treatment alone.

Birefringence of Zn(x)Cd(1-x)S near the isotropic point

The birefringence of the mixed crystal Zn0.14Cd0.86S has been measured near its isotropic point and found to be highly dispersive. The region of strong dispersion shifts to shorter wavelengths than observed in pure CdS, and its magnitude near the isotropic point is larger. These results are highly significant for the development of narrowband dispersive birefringent filters in the blue-green region of the spectrum.