Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer

BACKGROUND

Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.

MATERIALS AND METHODS

Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.

RESULTS

One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.

CONCLUSION

Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

Intracranial volume and dementia: some evidence in support of the cerebral reserve hypothesis

The brain reserve hypothesis has been posited as being one important mediating factor for developing dementia, especially Alzheimer's disease (AD). Evidence for this hypothesis is mixed though different methodologies have made these findings difficult to interpret. We examined imaging data from a large cohort (N=194) of mixed dementia patients and controls, 65years old and older from the Cache County, Utah Study of Memory and Aging for evidence of the brain reserve hypothesis using total intracranial volume (TICV) as a quantitative measure of pre-morbid brain size and a vicarious indicator of reserve. A broader spectrum of non-demented elderly control subjects from previous studies was also included for comparison (N=423). In addition, non-parametric Classification and Regression Tree (CART) analyses were performed to model group heterogeneity and identify any subgroups of patients where TICV might be an important predictor of dementia. Parametrically, no main effect was found for TICV when predicting a dementia diagnosis; however, the CART analysis did reveal important TICV subgroups, including a sex differential wherein ε4 APOE allele presence in males and low TICV predicted AD classification. TICV, APOE, and other potential mediator/moderator variables are discussed in the context of the brain reserve hypothesis.

Long-term reproducibility of ambulatory blood pressure is superior to office blood pressure in the very elderly

While it is known that reproducibility of ambulatory blood pressure (BP) is superior to office BP in middle-aged subjects, little is known older age groups. Hence, we compared the long-term reproducibility of ambulatory and office BP readings in subjects over the age of 75 years. A cohort of 72 subjects 75-90 years of age (mean, 82 years at baseline) had repeat office and ambulatory blood pressures 2 years apart under similar conditions. On the same day, patients underwent office BP measurements by a semi-automated device and then by ambulatory BP monitoring. Awake and sleep periods were divided according to a diary kept by each patient. The agreement between studies was assessed using the standard deviation of the differences (SDD) and Bland-Altman plots. There were minimal mean changes in office, 24-hour, awake and sleep mean BP values between baseline and 2 years later. The SDDs between visits were lower for 24-hour BP compared to the office BP (11.7/5.9 mmHg versus 17.8/9.0 mmHg, p < 0.01). The SDD for 24-hour BP was also lower than the SDDs for the awake and sleep BP (p < 0.05). Nocturnal BPs defined by absolute values were more reproducible than categories of dippers and non-dippers. These data demonstrate that long-term reproducibility of 24-hour BP is superior to office measurements for very elderly subjects. In a clinical trial involving this age group, far fewer subjects would be required if 24-hour BP was the primary efficacy endpoint rather than the office BP.

Fulminant intravascular lymphoma presenting as fever of unknown origin

Intravascular large cell lymphoma (IVLL) is a rare neoplasm characterized by the proliferation of malignant lymphoid cells within the lumens of small to medium-sized blood vessels. The central nervous system, skin, and endocrine systems are most commonly involved. IVLL may disseminate to the heart, pancreas, liver, spleen, kidneys, and adrenal glands. We report a 52-year-old patient who was admitted for fever of unknown origin for 3 weeks, jaundice and abnormal liver function tests. Fever, high levels of bilirubin, severe anemia, thrombocytopenia, and a very fulminant course characterized the clinical picture. Although bone marrow involvement is quite rare, the diagnosis of IVLL in this patient was done by bone marrow biopsy. The patient was treated with CHOP protocol and received the first course but the aggressive disease led to the patient's death.

Gait and balance dysfunction: a model of the interaction of age and disease

This article reviews age-associated changes in gait, balance, and sensorimotor function and contrasts them to the changes that occur as a result of disease. Strength peaks in the mid-20s but declines only modestly until the fifth decade, after which there is rapid decline. All aspects of sensory function diminish with age, resulting in modest sensory changes in older patients. Gait speed is stable until the seventh decade and thereafter slows modestly. Age-related changes in the balance of older persons result in an effective response that meets routine needs but may be ineffective under demanding circumstances capable of producing response. Thus, these modest age-related decrements may be an element in the increased incidence of falls in older people. The loss of function caused by disease is of greater magnitude as well as being superimposed on that caused by age and thus may lead to a failure of mobility. Neurologic diseases that impair sensorimotor function compromise mobility in a manner consistent with the deficits that they produce. In mobility dysfunction caused by white matter lesions, the gait/balance abnormalities may not have unique clinical features, making diagnosis difficult. We used quantitative MRI to study the brains of older subjects with mobility impairment. The volume of white matter lesions in mobility-impaired subjects was double that of controls and was unrelated to increasing age, suggesting that white matter lesions are a disease-related rather than an age-related occurrence. We also used stance perturbation evoked potentials to demonstrate delayed conduction in some mobility-impaired older subjects. Prolonged sensory conduction may contribute to maladaptive balance and thus may be useful for diagnosis. Contemporary imaging and neurophysiology thus provides insight into the pathophysiology of mobility impairment and allows for more accurate diagnosis.

Unexplained systemic symptoms and Gallium-67--guided decisions

Over 3 months, a healthy man developed prominent systemic symptoms that defied investigation. Physical examination was noncontributory, and extensive studies revealed only a marked acute-phase response associated with increased serum IL-6 levels. A whole body Gallium-67 scan was crucial in diagnosis, directing attention to high uptake in the left paraspinal and psoas muscles. Open surgical excision biopsy was performed, guided by intraoperative use of a gamma-probe. Removed tissue was diagnosed as diffuse, large B-cell non-Hodgkin lymphoma of muscle (stage IE), a rare extranodal lymphoma. Cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy was given, and the patient became asymptomatic with normal blood tests and was thought to be in remission. However, a repeat Gallium-67 scan revealed recurrent multifocal disease and salvage chemotherapy was instituted. A 47,XXY karyotype (Klinefelter syndrome) was later identified, possibly associated with the lymphoma.

Interpersonal psychotherapy for late-life depression: past, present, and future

Interpersonal psychotherapy (IPT) has demonstrated efficacy in protecting against a recurrence of major depression in elderly subjects when used alone on a monthly basis and when combined with antidepressant medication. The authors summarize their experience using IPT over the past 10 years and discuss a variety of treatment correlates. In addition, preliminary results using IPT combined with paroxetine in depressed elders reveals no difference in remission rates between cognitively intact and cognitively impaired depressed elders.

White matter abnormalities in mobility-impaired older persons

OBJECTIVE

To investigate the relationship between white matter abnormalities and impairment of gait and balance in older persons.

METHODS

Quantitative MRI was used to evaluate the brain tissue compartments of 28 older individuals separated into normal and impaired groups on the basis of mobility performance testing using the Short Physical Performance Battery. In addition, individuals were tested on six indices of gait and balance. For imaging data, segmentation of intracranial volume into four tissue classes was performed using template-driven segmentation, in which signal-intensity-based statistical tissue classification is refined using a digital brain atlas as anatomic template.

RESULTS

Both decreased white matter volume, which was age-related, and increased white matter signal abnormalities, which were not age-related, were observed in the mobility-impaired group compared with the control subjects. The average volume of white matter signal abnormalities for impaired individuals was nearly double that of control subjects.

CONCLUSIONS

This cross-sectional study suggests that decreased white matter volume is age-related, whereas increased white matter signal abnormalities are most likely to occur as a result of disease. Both of these changes are independently associated with impaired mobility in older persons and therefore likely to be additive factors of motor disability.

Reliability and responsiveness of two physical performance measures examined in the context of a functional training intervention

BACKGROUND AND PURPOSE

The reliability and responsiveness of 2 physical performance measures were assessed in this nonrandomized, controlled pilot exercise intervention.

SUBJECTS

Forty-five older individuals with mobility impairment (mean age=77.9 years, SD=5.9, range=70-92) were sequentially assigned to participate in an exercise program (intervention group) or to a control group.

METHODS

The intervention group performed exercise 3 times a week for 12 weeks that targeted muscle force, endurance, balance, and flexibility. Outcome measures were the 8-item Physical Performance Test (PPT-8) and the 6-minute walk test. Test-retest reliability and responsiveness indexes were determined for both tests; interrater reliability was measured for the PPT-8.

RESULTS

The intraclass correlation coefficient for interrater reliability for the PPT-8 was. 96. Intraclass correlation coefficients for test-retest reliability were.88 for the PPT-8 and.93 for the 6-minute walk test. The intervention group improved 2.4 points and the control group improved 0.7 point on the PPT-8, as compared with baseline measurements. There was no change in 6-minute walk test distance in the intervention group when compared with the control group. The responsiveness index was.8 for the PPT-8 and.6 for the 6-minute walk test.

CONCLUSION AND DISCUSSION

Measurements for both the PPT-8 and the 6-minute walk test appeared to be highly reliable. The PPT-8 was more responsive than the 6-minute walk test to change in performance expected with this functional training intervention.

Stance perturbation-evoked potentials in old people with poor gait and balance

OBJECTIVE

Cerebral cortical potentials can be evoked by stance perturbation, and there is speculation that they represent the activation of supraspinal centers in preparation for the control and coordination of motor movements that maintain balance. We sought to determine if these potentials differed in old people at risk of falls.

METHODS

Cortical potentials were generated by the sudden forward translation of a weight-bearing platform in 8 healthy young subjects and in 33 old subjects stratified by their functional capacity. Dependent measures were compared with non-parametric tests of significance.

RESULTS

Perturbing the stance of young subjects produced a biphasic scalp potential centered at the vertex with an early positive peak at 60 ms and a larger, 45 microV, negative peak at 123 ms. In old subjects the response was delayed and the vertex-negative component was smaller and bifid. The interval between the two components of the negative peak was prolonged in a subgroup of old subjects with reduced mobility.

CONCLUSIONS

Delays in sensory conduction may play a role in subsequent maladaptive motor responses to stance perturbation that can result in falls and injury in old people.

Using interpersonal psychotherapy (IPT) in a combined psychotherapy/medication research protocol with depressed elders. A descriptive report with case vignettes

One hundred eighty subjects at least 60 years of age with recurrent unipolar major depression were recruited to participate in a depression treatment protocol. All patients received drug therapy with nortriptyline (NT) and interpersonal psychotherapy (IPT) with an experienced clinician. Acutely, 81% of subjects showed a full response to combined treatment. In the initial 127 subjects, the most common problem areas in therapy were role transition (41%), interpersonal disputes (34.5%), and grief (23%). Case vignettes are presented and discussed. The combination of IPT and NT showed a powerful antidepressant effect. IPT was readily adaptable to the needs of depressed elders.

Balance and strength training in older adults: intervention gains and Tai Chi maintenance

OBJECTIVE

To determine the effect on balance and strength of 3 months of intensive balance and/or weight training followed by 6 months of low intensity Tai Chi training for maintenance of gains.

DESIGN

Randomized control intervention. Four groups in 2 x 2 design: Control, Balance, Strength, Balance + Strength, using blinded testers.

SETTING

Exercise and balance laboratory at University of Connecticut Health Center.

PARTICIPANTS

Subjects were 110 healthy community dwellers (mean age 80) who were free of dementia, neurological disease, and serious cardiovascular or musculoskeletal conditions.

INTERVENTIONS

Short-term training (3 months) occurred 3 times/week (45 minutes Balance and Strength, 90 minutes Balance + Strength). Balance training included equilibrium control exercises of firm and foam surfaces and center-of-pressure biofeedback. Strengthening consisted of lower extremity weight-lifting. All subjects than received long-term group Tai Chi instruction (6 months, 1 hour, 1 time/week).

MEASUREMENTS

Losses of balance during Sensory Organization Testing (LOB), single stance time (SST), voluntary limits of stability (FBOS), summed isokinetic torque of eight lower extremity movements (ISOK), and usual gait velocity (GVU).

RESULTS AND CONCLUSIONS

Balance training meaningfully improved all balance measures by restoring performance to a level analogous to an individual 3 to 10 years younger: LOB = -2.0 +/- 0.3 (adjusted paired differences, P < .005 ANOVA); SST = 7.0 +/- 1.2 sec; and FBOS = 9.0 +/- 2.0% of foot length (P < .05). Strengthening increased ISOK by 1.1 +/- 0.1 Nm kg-1 (P < .005). There was no interaction between balance and strength training. Significant gains persisted after 6 months of Tai Chi, although there was some decrement.

Strength is a major factor in balance, gait, and the occurrence of falls

We studied the effects of lower extremity strength as well as gait and balance on the occurrence of falls in nursing home residents. Nursing home residents with a history of falls had less than half of the knee and ankle strength of nonfalling subjects residing in the same home. The differences were more prominent at the ankle than the knee, and were most pronounced in the ankle dorsiflexors, where they were one-tenth that of controls. Also of note was the fact that this same group of fallers had slowed gait velocity (58% of control) as well as an impaired response to postural perturbation as determined on the Postural Stress Test (55% of control). In a recently completed study we measured strength as balance (EquiTest balance platform) of community-dwelling subjects. The occurrence of loss of balance during the sensory organization test was correlated with diminished lower extremity (Pearson R = -.36, p = .001) as well as ankle dorsi and plantar flexion moments (Pearson R = -.37, p = .001). Using a logistic regression model, we demonstrated an independent effect of strength on the odds ratio of an SOT-LOB; for each newtonmeter per kg increase in strength there was a 20% decrease (95% CI, .74-87) in the odds ratio. The data from both nursing home and community-dwelling subjects indicate a strong relationship of lower extremity strength to balance and gait. The nursing home studies demonstrated an association between these functions and the occurrence of falls.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between tps and cea in patients with colorectal-cancer

Serum TPS and CEA levels were measured in 173 cancer patients with various disease stages. The patients were divided into 4 groups: preoperative group, 16 patients in whom TPS and CEA were measured pre- and postoperatively; group I, 66 newly diagnosed patients up to 40 days post surgery; group II, 86 patients whose blood was taken 40-365 days post surgery, and group III, 47 patients on long-term follow-up in whom blood was taken more than one year after surgery. The median preoperative TPS levels were significantly higher (p<0.01) than the postoperative levels. Patients with Dukes' D had significantly higher TPS (p<0.01) and CEA levels as compared to patients with Dukes' B or C. For both Dukes' B and C stages there was a significant increase in median TPS level between group I and II and III. There was no similar increase in median CEA level. Serial measurements in individual patients show a significant increase in TPS levels between groups I, II and III. In Dukes' D patients, individual TPS levels decreased in response to therapy. There was a significant correlation between TPS and CEA levels. These results suggest that TPS measurement is additive to CEA in follow-up of asymptomatic patients, and to monitor response to therapy in patients with metastatic disease.

Functional base of support decreases with age

BACKGROUND

Poor balance in older persons increases the risk of injurious falls during daily activities. Functional base of support (FBOS), the anterior-posterior proportion of foot length used in maximal sustained forward and backward leaning, tests controlled center of mass movement, a component of balance required in daily activities. The purpose of this study was to examine the relationship between FBOS and age and establish the reliability of this measure.

METHODS

Subjects were 113 community-dwelling men and women, ages 20 to 91. FBOS, measured on a force platform, is the difference between mean center of pressure location during sustained forward and backward leaning, divided by foot length. Forward lean (FL), backward lean (BL), and average sway distance during normal standing (STAND SWAY) and while leaning (FBOS SWAY) were also measured.

RESULTS

Mean FBOS was .60 +/- .07 in subjects under age 60, and .42 +/- .12 in subjects 60 and older. FBOS remained constant in younger subjects; beyond age 60, FBOS declined about 16% per decade and was more variable. FL and BL also declined with age, remaining 66% and 34% of FBOS, respectively. STAND SWAY and FBOS SWAY were significantly correlated with each other, but not with FBOS.

CONCLUSIONS

FBOS is a reliable measure and is decreased on average in older persons. This decrease is not related to increased sway while standing or leaning. FBOS is a simple force platform test that has potential as a measure of change in this dimension of balance and as a predictor of falls risk in older persons.

Gender differences in the balance of healthy elderly as demonstrated by dynamic posturography

BACKGROUND

Prior studies indicate that older women fall more often than men although there is no evidence of gender-based balance differences. Using a force platform, we measured the effects of restricted sensory input and support surface movement to detect gender differences in balance.

METHODS

Healthy, elderly community dwellers (N = 234, mean age = 76 +/- 5 years, 52% female) were administered the following perturbations on the balance platform: The platform and/or visual surround were fixed or tilted proportionally to the subject's sway with the eyes open or closed, forward or backward horizontal translations, and toes-up and toes-down rotations.

RESULTS

Gender-based balance differences were not present during quiet standing, or when the support surface or visual input were manipulated separately. Women swayed and lost their balance more than men when the surface was sway-referenced while vision was compromised, but by the third trial their sway control was comparable to the men. Women also initially lost their balance more frequently than men during toes-up and -down rotations, and compared to men continued to lose their balance more often during repeated toes-up rotations. Finally, women developed less angular momentum than men in response to forward platform rotations.

DISCUSSION

Elderly women show impairments of balance when simultaneously deprived of visual and somatosensory inputs or during a backwards destabilization. Since there is little evidence for a CNS source for such gender differences, biomechanical origins (e.g., dorsiflexion strength and range of motion) are a more likely cause. Limited postural control of women under conditions stressing balance may explain their greater frequency of falling.

Applying interpersonal psychotherapy to bereavement-related depression following loss of a spouse in late life

The efficacy of interpersonal psychotherapy (IPT) as a treatment for outpatients with major depression has been documented in several controlled trials. Recently, IPT has been adapted specifically for depression in late life. The authors report on their experience in applying IPT to geriatric patients whose depression is temporally linked to the loss of their spouses. Detailed treatment techniques are illustrated with case vignettes. Preliminary treatment outcomes are presented for 6 subjects who showed a mean change on the 17-item Hamilton Rating Scale for Depression from 18.5 ± 2.3 SD to 7.2 ± 4.6 after an average of 17 weekly IPT sessions. IPT appears to be an effective short-term treatment for bereavement-related depression in elderly subjects.

Altered sensory function and balance in older persons

The effects of three different visual inputs (eyes open, eyes closed, and inaccurate) while standing on an unstable surface (respectively, UEO, UEC, UI) were compared in a group of healthy elderly community dwellers (N = 239; mean age 76) and young (N = 34; mean age 34) adults. Subjects with medical factors known to affect balance were excluded. Body sway and loss of balance measured dynamic force platform (EquiTest, NeuroCom International). Visual and somatosensory inputs were rendered inaccurate through tilting of the standing surface and/or the visual surround proportional to the subject's angle of sway (sway-referencing). The elderly group had significantly more difficulty balancing during UEC and UI, and a larger proportion lost their balance during UI. These findings are compared to those of other dynamic posturography studies in which sensory inputs were controlled. Issues of age, frailty, screening, and test protocol are addressed in order to account for differences in results among studies.

Training balance and strength in the elderly to improve function

Short-term exposure to altered sensory input or destabilizing platform movement results in significant improvement in sway control and inhibition of inappropriate motor responses, resulting in improved balance during repetitive testing. In addition, there is recent evidence that strength and function can be increased in both active and frail elderly who participate in strength training programs. Therefore, the hypotheses to be tested are that (1) balance training alone, or (2) strength training alone will each be capable of significantly improving balance, gait, and functional mobility, and that (3) a combined program of balance and strength training will be more effective than either approach alone. These hypotheses will be tested relative to a control group, using a 2 x 2 design (30 subjects per group), in a community-dwelling elderly at least 75 years of age. Intervention sessions of at least 45 minutes will occur three times per week for 3 months, with 6 months of follow-up, home-based Tai Chi training. The primary outcome variable is a basic measure of functional balance, ie, the occurrence of loss of balance during tilts of the support and/or movement of the visual surround.

A dynamic posturography study of balance in healthy elderly

Using dynamic posturography, we studied the balance of 234 community-dwelling elderly subjects (mean age, 76 +/- 5 years) as well as 34 young controls (mean age, 34 +/- 12 years). Almost all measures of balance were worse in elderly subjects compared with young controls. The decrements in older persons indicate a diminished capacity to process conflicting sensory input as well as a possible narrowing of the limit of stability (or, alternatively, an increase in sway). We propose that this occurs most likely as a result of biomechanical or central processing changes as opposed to diminished sensory or vestibular input. Furthermore, with difficult tasks sequentially presented, the performance of the older subjects improved, suggesting that balance, at least in the short term, adapts to stressful conditions. In these elderly subjects screened for age-related diseases affecting balance, only small decrements of balance occurred between the ages of 70 and 85 years. This nominal decrease over a 15-year span suggests that clinically significant balance impairment is the result of age-related disease rather than an inevitable consequence of aging and is therefore potentially treatable.

Gait assessment in the elderly: a gait abnormality rating scale and its relation to falls

We evaluated the gait of 49 nursing home residents (27 of whom had a history of recent falls), and 22 controls. Measures consisted of stride length and walking speed, as well as a videotape-based analysis of 16 facets of gait. The study demonstrates that stride length, walking speed, and the assessment of videotaped gait correlated well with each other and were significantly impaired in fallers compared to controls. Arm swing amplitude, upper-lower extremity synchrony, and guardedness of gait were most impaired in fallers. Although subjects who fell were more often demented than controls, it is likely that this represents a selection bias in nursing homes. Visual rating of gait features in the nursing home population is a simple and useful alternative to established methods of gait analysis.

Peripheral giant cell granuloma during orthodontic treatment

Inflammatory and hyperplastic gingival responses during orthodontic treatment are common. These may complicate the actual treatment and may require periodontal therapy. The present report describes the development of an interproximal enlarged peripheral giant cell granuloma during orthodontic treatment, resulting in migration and separation of the neighboring teeth and resorption of the interproximal alveolar septum and molar root. The lesion was excised and the bone was curetted; this led to spontaneous migration of the involved teeth to their natural positions.

Brain white-matter changes in the elderly prone to falling

Falls and impaired gait are a major source of morbidity in the elderly. Why some elderly become prone to falling is often unclear. We analyzed the gait, equilibrium, and brain computed tomography results of 40 elderly subjects without evidence of neurologic disease known to be associated with falls. Twenty of these subjects were prone to falling and the remaining 20 were nonfalling controls. These two groups were comparable in terms of age and sex (mean age, 83.3 years [SE, 1.7 years]). The group of fallers had significantly worse gait and equilibrium scores and a greater degree of white-matter hypodensity on computed tomography. White-matter hypodensity correlated with impaired gait and equilibrium scores but not with impaired performance on cognitive testing. This study reveals the association of white-matter disease with gait and balance impairment leading to falls in the elderly.

Clinico-pathologic studies in dementia: nondemented subjects with pathologically confirmed Alzheimer's disease

We compared neuropsychological findings in 28 longitudinally evaluated elderly subjects with their postmortem neuropathology, including senile plaque and neurofibrillary tangle counts from standardized sections. Nine of the subjects were not demented when evaluated just prior to their death. Numerous cortical senile plaques and other changes of Alzheimer's disease (AD) occurred in six of nine nondemented old-old subjects. Five of these six subjects had shown decline on yearly neuropsychological tests but their cognitive impairment was too mild to meet clinical criteria for dementia. Whereas cortical senile plaque count did not distinguish well between demented and nondemented subjects, every subject with numerous cortical neurofibrillary tangles was demented. The nondemented subjects with Alzheimer pathology may have had "preclinical" AD, or numerous cortical plaques may occur in some elderly subjects who would never develop clinical dementia.

The effects of L-DOPA on regional cerebral blood flow and oxygen metabolism in patients with Parkinson's disease

Studies performed on 18 patients with Parkinson's disease and 6 control subjects have shown that acute administration of L-DOPA in clinically effective doses gives rise to a diffuse increase in regional cerebral blood flow without accompanying stimulation of regional oxygen utilization. The data suggest that this rise in rCBF is caused by vasodilatation due to a direct action of the drug on the cerebral blood vessels. The effect of L-DOPA on rCBF did not correlate with the degree of clinical improvement seen in each patient after treatment. The therapeutic effect of L-DOPA in the brain was not reflected in any change of regional cerebral oxygen utilization as measured by our technique. We suggest that the pharmacological actions of L-DOPA in the brain take place on at least two different levels.

High-performance liquid chromatography with amperometric detection of plasma L-3,4-dihydroxyphenylalanine in Parkinsonian patients

An assay for the quantitative estimation of L-3,4-dihydroxyphenylalanine in human plasma has been developed, using alpha-methylnoradrenaline as internal standard and ion-pair reversed-phase (C8), isocratic high-performance liquid chromatography with amperometric detection. A citrate-phosphate buffer, pH 3.1, containing 2 mM EDTA disodium salt, 6.5 mM 1-octanesulphonic acid and 14% v/v methanol, provided good separation of the analytes from each other and from the carbidopa present in the plasma of Sinemet-treated Parkinsonian patients. The sensitivity, selectivity and precision of the method were found to be sufficient to enable its routine use for pharmacodynamic studies.

Quantitative cytocentrifugation in the evaluation of cerebrospinal fluid

Five hundred sixteen samples of cerebrospinal fluid (CSF) were subjected to cytocentrifugation to determine whether this technique is reliable in quantifying the cells present while simultaneously allowing precise cytologic identification of the types of malignant and atypical cells present. Cell counts obtained by the cytocentrifuge method were comparable to those obtained by the standard hemocytometer method. Because of the larger volume of fluid used in cytocentrifugation, cells (0.2/cu mm) were found in 264 specimens that would have been considered devoid of cells by hemocytometry. Six of these samples contained malignant cells. The Wright's-stained cytocentrifuged specimens also allowed precise identification of hematopoietic cell types. CSF cytocentrifugation offers the advantages of (1) a simple and rapid method of quantifying the number of cells present, (2) use of larger volumes than the hemocytometer method, thereby minimizing the possibility that the specimen will be classified as acellular, and (3) improved morphology of hematopoietic cell types by use of the Wright's stain. We conclude that the cytocentrifugation method is useful in the routine quantification and diagnosis of CSF specimens.

Treatment of myoclonus with L-5-hydroxytryptophan and carbidopa: clinical, electrophysiological, and biochemical observations

Six patients with myoclonus of varying cause were treated with L-5-hydroxytryptophan (L-5-HTP) and carbidopa. While spontaneous myoclonus decreased in three of the patients and action myoclonus in four, only two patients had marked functional improvement. Side effects included gastrointestinal and affective disturbances. L-5-HTP therapy caused a diminished frequency of paroxysmal discharges in the electroencephalograms of three patients which did not always correlate with clinical improvement. Lumbar cerebrospinal fluid 5-hydroxyindoleacetic acid (5-HIAA) concentration after probenecid was decreased in all patients prior to therapy, but this reduction did not predict treatment response. Urinary excretion patterns for 5-HTP, serotonin, and 5-HIAA during treatment were similar in responders and nonresponders. It is concluded that while some patients with myoclonus do benefit from L-5-HTP therapy, biochemical and electrophysiological tests are not useful predictors of treatment response, and the high incidence of side effects limits the usefulness of this therapy.

Quality and duration of survival in glioblastoma multiforme. Combined surgical, radiation, and lomustine therapy

A retrospective evaluation of the quality and length of survival of 74 patients nonrandomly receiving lomustine, 100 to 110 mg/sq m, following craniotomy and irradiation for glioblastoma multiforme was performed. After surgery all patients were capable of at least partial self-care. Patients receiving postoperative irradiation and lomustine had a median survival of 11.5 months. While receiving chemotherapy, 40% of these patients were capable of at least partial employment; 75% were able to care for themselves. These levels of function were stable for 70% of the average postoperative course (8.0 months), following which a decline ensued.

Anatomical correlates of electrical and behavioral events related to amygdaloid kindling

Anatomical structures demonstrating increased glucose uptake during the various stages of amygdaloid kindling in rats were identified by the 14C-2-deoxyglucose (DG) autoradiographic technique. Partial (stages 1 and 2) seizures were correlated with increased DG uptake in the ipsilateral amygdala and its direct projection fields. The appearance of generalized motor (stages 3,4, and 5) seizures was accompanied by less limbic involvement and recruitment of a bilateral system including substantia nigra, specific and nonspecific thalamic nuclei, globus pallidus, and neocortex. Increased hippocampal DG uptake was correlated with prolonged amygdaloid after discharge duration but not with the behavioral seizure stage. This study does not reveal which of these structures are responsible for the observed behavioral and electrical events and which are activated by them. It does suggest, however, that three discrete anatomical systems underlie the generation of partial seizures, generalized motor seizures, and local after discharge.