Self-reported eye contact sensitivity and face processing in chromosome 22q11.2 deletion syndrome

INTRODUCTION

22q11.2 deletion syndrome (22qDS) has been associated with varying levels of social impairments, and with atypical visual scanning of faces. The present study explored whether self-reported sensitivity to eye contact might be related to these phenomena.

METHOD

Individuals with confirmed 22qDS were interviewed about their experience and possible discomfort with eye contact. In cases where individuals expresesed discomfort, they were subsequently asked about coping mechanisms used to deal with this discomfort. In addition to self-reported eye contact discomfort, gaze to emotional faces was examined using eye tracking.

RESULTS

In the subgroup of individuals who reported discomfort during eye contact, eye tracking results revealed a lower amount of gaze in the eyes of neutral faces, as well as the absence of the typical left visual field (LVF) bias, indicative of alterations in hemispheric lateralization. This subgroup also scored lower on a measure of everyday functioning.

CONCLUSIONS

Our results show that, by simply asking individuals with this social and communicative disorder about eye gaze discomfort, we may better understand the specific challenges that they experience. Moreover, information gained from such first-person reports together with eye-tracking measures further informs about the integrity of their face processing system, as well as about the nature and degree of impairment in this population.

Neurodevelopmental and other psychiatric disorders in 22q11.2 deletion syndrome from childhood to adult age: Prospective longitudinal study of 100 individuals

The 22q11.2 deletion syndrome (22q11.2DS), affects physical as well as cognitive and emotional functioning with increased risk for psychiatric and behavioral problems. This longitudinal study of 79 individuals (18-50 years) with 22q11.2DS investigated neurodevelopmental (NDD) and psychiatric disorders in adulthood, evaluated the stability of childhood diagnoses over time, and examined associations between clinical characteristics in childhood/adolescence and diagnostic outcome in adult age. Examination using validated instruments for cognitive, psychiatric, and global functional problems in the context of an in-depth clinical evaluation found adult age stability of NDD diagnoses made in childhood, however, rates increased at follow-up. Rates of anxiety, mood, and psychotic disorders were high, with a majority meeting diagnostic criteria for one or more psychiatric disorder. The rate of psychotic disorders was much lower compared to many other studies. Variability in functioning at follow-up was primarily associated with intellectual ability at T1. The findings obtained highlight the increased risk of NDD and psychiatric problems and of cognitive impairment and reduced levels of global functioning over time. Results emphasize the importance of clinical follow-up to enable appropriate support for the promotion of optimal health along with a need for future research on effective interventions and treatment strategies.

Child Sexual Abuse-Challenging Conditions for Adult Oral Health: A Qualitative Study

The aim was to analyze perceptions of oral health in adults who have been exposed to child sexual abuse. Eleven participants (10 women), 19 to 56 y of age, who had experienced sexual abuse as children were purposively selected and interviewed in-depth. The participants were encouraged to describe how they perceived the effect of the sexual abuse on their oral health as adults. The interviews were recorded digitally and transcribed verbatim. The collected material was analyzed according to qualitative content analysis. The theme "challenging conditions for maintaining oral health" was identified, comprising 2 categories: first, "the emotional significance," with the subcategories 1) emotional barriers and 2) powerful relief, and second, "the obstacles to oral health," with the subcategories 1) daily self-care with complications and 2) dental appointments with difficulties. The findings indicate that the experience of sexual abuse during childhood can have a negative impact on oral care in adulthood. The informants stated that oral health was of utmost importance but also associated with strong emotions. There were obstacles to maintenance of oral health that were difficult to surmount.Knowledge Transfer Statement:The study provides access to the attitudes of survivors of child sexual abuse regarding oral health and the needs and obstacles that they experience. This is important knowledge for dental professionals to optimize dental care.

Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents: A Randomized Clinical Trial

IMPORTANCE

In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.

OBJECTIVE

To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.

DESIGN, SETTING AND PARTICIPANTS

A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.

INTERVENTIONS

Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.

RESULTS

Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).

CONCLUSIONS AND RELEVANCE

Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03263546.

Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder: A Trial Protocol for a Randomized Noninferiority Trial

Importance

Internet-delivered cognitive behavior therapy is an effective treatment for children and adolescents with obsessive-compulsive disorder and has the potential to markedly increase access to treatment for patients while being cost-effective for health care organizations.

Objective

To investigate whether internet-delivered cognitive behavior therapy implemented within a stepped care model is noninferior to, and cost-effective compared with, the gold standard of face-to-face cognitive behavior therapy for pediatric obsessive-compulsive disorder.

Design, Setting, and Participants

Multicenter, single-blind, randomized clinical noninferiority trial implemented at 2 specialist pediatric obsessive-compulsive disorder clinics in Stockholm and Gothenburg, Sweden. Participants are 152 children and adolescents aged 7 to 17 years with obsessive compulsive disorder, recruited through the 2 clinics and online self-referral. Patients will be randomized 1:1 to the stepped care intervention or face-to-face therapy. Blind evaluations will be conducted after treatment and at 3-month and 6-month follow-ups. At the 6-month follow-up (primary end point), noninferiority will be tested and resource use will be compared between the 2 treatment groups. Data will be analyzed according to intention-to-treat principles.

Intervention

Patients randomized to stepped care will first receive internet-delivered cognitive behavior therapy for 16 weeks; patients who are classified as nonresponders 3 months after treatment completion will receive additional face-to-face therapy. The control group will receive 16 weeks of face-to-face cognitive behavior therapy immediately following randomization and nonresponders at the 3-month follow-up will, as in the stepped care group, receive additional face-to-face therapy.

Main Outcomes and Measures

Noninferiority is defined as a 4-point difference on the primary outcome measure (Children's Yale-Brown Obsessive Compulsive Scale).

Discussion

Recruitment started October 6, 2017, and was completed May 24, 2019. Results from the primary end point will be available by May 2020. The naturalistic follow-ups (1, 2, and 5 years after the end of treatment) will continue to 2025. There are no interim analyses planned or stopping rules for the trial.

Trial Registration

ClinicalTrials.gov identifier: NCT03263546.

Process evaluation of a cluster randomised intervention in Swedish primary care: using care managers in collaborative care to improve care quality for patients with depression

Background

The collaborative care model with a care manager has previously generated beneficial results for patients with depression in terms of decreased burden of depression symptoms. A care manager function has been tested in Sweden in the PRIM-CARE RCT with successful results. The aim of the present study was to evaluate the process of implementing care managers in collaborative care for patients with depression in Swedish primary health care in the PRIM-CARE RCT.

Methods

The study followed UK Medical Research Council guidance for process evaluation.

Field notes from the implementation of the PRIM - CARE RCT were used, as well as data collected from five focus group discussions with General Practitioners (n = 29) and three focus group discussions with care managers (n = 11). Data were analysed with content analysis.

Results

Training sessions, careful preparation and extensive initial support to the care manager and staff at the Primary Care Centres were important ingredients in the implementation. The close access to facilitators, the recurrent peer support meetings, and the weekly newsletter strengthened the care manager function.

Conclusions

A complex intervention adapted to the Swedish primary care context focusing on a care manager function for patients with depression could be performed through a stepwise implementation process. Financial support from the health care regions included in the study helped to reduce the impact of identified barriers. This process evaluation has revealed new and important knowledge for primary care development concerning infrastructure and organization building, knowledge sharing, and facilitating factors and barriers.

Trial registration

NCT02378272 Care Manager – Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM – CARE). Registered March 4 2015. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0998-4) contains supplementary material, which is available to authorized users.

Paediatric acute-onset neuropsychiatric syndrome in children and adolescents: an observational cohort study

BACKGROUND

Paediatric acute-onset neuropsychiatric syndrome (PANS) is a newly defined symptom-based condition that mainly occurs in children and adolescents. Few studies have described the clinical characteristics of the syndrome.

METHODS

We clinically assessed and reviewed the medical histories of children and adolescents (aged 4-14 years) with suspected PANS who were referred to a specialist clinic in Gothenburg, Sweden, by local paediatricians and child psychiatrists. We scored severity of symptoms and impairment retrospectively for the timepoint with the most severe symptoms using the PANS scale.

FINDINGS

Of 41 patients (37 referred and four visited upon parents' request), 23 (ten girls and 13 boys) met PANS diagnostic criteria. Mean age at PANS onset was 8·5 years (SD 3·37). 11 (48%) patients had a family history of developmental or neuropsychiatric disorders in a first-degree relative and 11 (48%) had a family history of autoimmune or inflammatory diseases in a first-degree relative. 17 (74%) patients had been previously diagnosed with a developmental disorder (n=5) or had symptoms indicative of developmental problems (n=12). A verified or suspected infection was temporally related to PANS onset in all patients; the infection was bacterial in ten (43%) patients (eight had streptococcal infection and two an infection caused by other bacteria) and viral in 13 (57%) patients. All patients had a relapsing-remitting course of illness. The mean PANS scale symptom score was 46 (SD 3·67) and the mean impairment score was 45 (2·74). Antibiotic treatment was reported as beneficial by the parents of 12 (63%) of the 19 children who received antibiotics.

INTERPRETATION

Our PANS cohort had severe, acute-onset, complex neuropsychiatric symptoms, a relapsing-remitting symptom course, and possible infectious triggers. Further research into the cause of, and appropriate treatment for, PANS is warranted.

FUNDING

Swedish Brain Foundation.

Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam

BACKGROUND

If millions of neonatal deaths each year are to be prevented, one crucial component that must be improved is adequate care-seeking behaviour and effective use of existing health care systems. We have investigated these factors in relation to delivery and the neonatal period in a province in Northern Vietnam, a setting currently in socio-economic transition.

METHODS

Information on births and neonatal deaths between January and December 2005 in Quang Ninh province was collected. Narratives of the neonatal deaths were gathered and information about care-seeking in relation to delivery and illness was extracted. This information was then compared with the time and place of delivery and death.

RESULTS

We registered 17,519 births and 284 neonatal deaths occurring between January and December 2005. The neonatal mortality rate varied from 7.5/1000 to 38/1000, depending on the place of delivery. A quarter of the neonatal deaths had no contact with the health-care system at the time of death. Neonatal death within 24 hours of birth was more likely when the mother did not seek care at the time of delivery, or did so at the lowest level of the system (chi2=35.5, p<0.001). Mothers of ethnic minorities were more likely to exhibit this care-seeking behaviour at delivery.

CONCLUSION

Further improvement in neonatal survival can be achieved by changes in health system utilisation that aim to secure safe delivery for pregnant women. More efforts at local level are needed to encourage adequate care-seeking.

Categorical and dimensional aspects of co-morbidity in obsessive-compulsive disorder (OCD)

OBJECTIVE

Obsessive-compulsive disorder (OCD) defined at the diagnostic level encompasses divergent symptoms and is often associated with other psychiatric problems. The present study examines OCD versus co-morbid symptom patterns in OCD in children and adolescents in order to investigate the presence of diagnostic heterogeneity.

SUBJECTS AND METHODS

A total of 113 outpatients with primary OCD participated. The patients' and primary caretakers' responses on semi-structured interviews (child version of Schedule for Affective Disorders and Schizophrenia and the Children's Yale-Brown Obsessive Compulsive Scale) and parents' responses on the Child Behaviour Checklist were used in the study. Psychiatric diagnoses were related to CBCL syndrome scores and CBCL scores were compared with the Swedish normative data.

RESULTS

Co-morbid diagnoses were very common and only one out of five patients had only OCD. The most common group was the neuropsychiatric disorders (47%) where tic disorders were most common (27%), especially among boys (40.8%; P = .006, Fisher's exact test). Also anxiety disorders were common (39.8%) as were affective disorders (24.8%) neither with any gender differences. Diagnoses of disruptive disorders were less common (8.8%), almost exclusively of the oppositional kind (ODD) (8.8%). From the dimensional point of view using the CBCL, patients with OCD scored higher than Swedish youngster generally do, and some gender differences were seen in that girls scored higher on anxiety and depression while both girls and boys had high scores on thought problems, attention problems and especially aggressive behaviour. Comorbidities explained from 25 to 50% scores of the CBCL sub-syndrome scales, often with both main effects and through complex patterns of interaction with gender, OCD-severity and other co-morbid problems.

CONCLUSIONS

While co-morbid problems is an important facet of OCD, sub-syndromal levels of symptoms that can be assessed using a dimensional approach, is a large part of the total symptom burden in these youngsters. Our data indicate contributions of different pathways for girls and for boys for several comorbid problems together with OCD-severity.

Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants

AIM

To describe the impact of prematurity, size at birth, neonatal disorders and the families' socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants.

METHODS

Prospective population-based cohort study. Data on breastfeeding, registered in databases in two Swedish counties in 1993-2001, were matched with data from two national registries: the Medical Birth Registry and Statistics Sweden. Mothers of 225 very preterm singleton infants were identified and included.

RESULTS

Seventy-nine percent of the mothers breastfed at 2 months, 62% at 4 months, 45% at 6 months, 22% at 9 months and 12% at 12 months. Prematurity, size at birth and neonatal disorders did not show an effect on breastfeeding duration. Being adversely exposed to any of the SES factors (maternal education, unemployment benefit, social welfare and equivalent disposable income in the household) was significantly associated with earlier weaning up to 6 months of infants' postnatal age.

CONCLUSIONS

This study shows new and noteworthy results concerning breastfeeding duration in mothers of very preterm infants, which was not influenced by degree of prematurity, size at birth or neonatal disorders but was affected by SES. This highlights the need for improved support of socioeconomically disadvantaged mothers, during and after the hospital stay.

Serotonin and superior mesenteric artery resistance index

OBJECTIVE

Serotonin is a vasoactive neuroendocrine substance and serotonergic drugs are promising agents for the treatment of functional gastrointestinal disorders. The effect of serotonin on superior mesenteric blood flow in humans is unknown. The aim of this study was to examine the effect of exogenous serotonin on superior mesenteric artery blood flow, as estimated by the resistance index with Doppler ultrasound, in healthy human volunteers.

MATERIAL AND METHODS

Six fasting healthy adult volunteers of both genders were studied. Transabdominal Doppler ultrasound was used to evaluate the effects of either a standard meal or intravenous infusion of serotonin (2.5-20 nmol kg-1 min-1) on the superior mesenteric artery resistance index, platelet-depleted plasma levels of serotonin, blood pressure, heart rate and electrocardiogram.

RESULTS

All subjects had the same patterns of response to meal and serotonin stimulation. Meal stimulation decreased the mean resistance index from 0.84+/-0.04 to 0.72+/-0.02 (p = 0.0004) and increased platelet-depleted-plasma levels of serotonin from 50+/-36 to 61+/-46 nmol L-1 (p = 0.04). Serotonin stimulation increased the mean resistance index from 0.82+/-0.04 to 0.88+/-0.03 (p = 0.006) and mean platelet-depleted-plasma levels of serotonin from 44+/-24 to 83+/-37 nmol L-1 (p = 0.03). Most subjects reported minor short-lived adverse effects. Electrocardiogram results were unchanged during all examinations.

CONCLUSIONS

We conclude that intravenous infusion of serotonin increases the resistance index of the superior mesenteric artery (increases downstream resistance) in healthy adult volunteers.

Effect of serotonin on small intestinal contractility in healthy volunteers

The physiological significance of serotonin released into the intestinal lumen for the regulation of motility is unknown in humans. The aim of this study was to evaluate the effect of serotonin infused into the lumen of the gastric antrum, duodenum or the jejunum, on antro-duodeno-jejunal contractility in healthy human volunteers. Manometric recordings were obtained and the effects of either a standard meal, continuous intravenous infusion of serotonin (20 nmol/kg/min) or intraluminal bolus infusions of graded doses of serotonin (2.5, 25 or 250 nmol) were compared. In addition, platelet-depleted plasma levels of serotonin, blood pressure, heart rate and electrocardiogram were evaluated. All subjects showed similar results. Intravenous serotonin increased migrating motor complex phase III frequency 3-fold and migrating velocity 2-fold. Intraluminal infusion of serotonin did not change contractile activity. Platelet-depleted-plasma levels of serotonin increased 2-fold following both intravenous and high doses of intraluminal infusions of serotonin. All subjects reported minor short-lived adverse effects following intravenous serotonin stimulation, while only half of the subjects reported minor short-lived adverse effects following intraluminal serotonin stimulations. We conclude that exogenous serotonin in the lumen of the upper part of the small intestine does not seem to change antro-duodeno-jejunal contractility significantly in healthy adult volunteers.

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis

BACKGROUND

This randomized clinical trial compared long-term outcome after antireflux surgery with acid inhibition therapy in the treatment of chronic gastro-oesophageal reflux disease (GORD).

METHODS

Patients with chronic GORD and oesophagitis verified at endoscopy were allocated to treatment with omeprazole (154 patients) or antireflux surgery (144). After 7 years of follow-up, 119 patients in the omeprazole arm and 99 who had antireflux surgery were available for evaluation. The primary outcome variable was the cumulative proportion of patients in whom treatment failed. Secondary objectives were evaluation of the treatment failure rate after dose adjustment of omeprazole, safety, and the frequency and severity of post-fundoplication complaints.

RESULTS

The proportion of patients in whom treatment did not fail during the 7 years was significantly higher in the surgical than in the medical group (66.7 versus 46.7 per cent respectively; P=0.002). A smaller difference remained after dose adjustment in the omeprazole group (P=0.045). More patients in the surgical group complained of symptoms such as dysphagia, inability to belch or vomit, and rectal flatulence. These complaints were fairly stable throughout the study interval. The mean daily dose of omeprazole was 22.8, 24.1, 24.3 and 24.3 mg at 1, 3, 5 and 7 years respectively.

CONCLUSION

Chronic GORD can be treated effectively by either antireflux surgery or omeprazole therapy. After 7 years, surgery was more effective in controlling overall disease symptoms, but specific post-fundoplication complaints remained a problem. There appeared to be no dose escalation of omeprazole with time.

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis

BACKGROUND

This randomized clinical trial compared long-term outcome after antireflux surgery with acid inhibition therapy in the treatment of chronic gastro-oesophageal reflux disease (GORD).

METHODS

Patients with chronic GORD and oesophagitis verified at endoscopy were allocated to treatment with omeprazole (154 patients) or antireflux surgery (144). After 7 years of follow-up, 119 patients in the omeprazole arm and 99 who had antireflux surgery were available for evaluation. The primary outcome variable was the cumulative proportion of patients in whom treatment failed. Secondary objectives were evaluation of the treatment failure rate after dose adjustment of omeprazole, safety, and the frequency and severity of post-fundoplication complaints.

RESULTS

The proportion of patients in whom treatment did not fail during the 7 years was significantly higher in the surgical than in the medical group (66.7 versus 46.7 per cent respectively; P=0.002). A smaller difference remained after dose adjustment in the omeprazole group (P=0.045). More patients in the surgical group complained of symptoms such as dysphagia, inability to belch or vomit, and rectal flatulence. These complaints were fairly stable throughout the study interval. The mean daily dose of omeprazole was 22.8, 24.1, 24.3 and 24.3 mg at 1, 3, 5 and 7 years respectively.

CONCLUSION

Chronic GORD can be treated effectively by either antireflux surgery or omeprazole therapy. After 7 years, surgery was more effective in controlling overall disease symptoms, but specific post-fundoplication complaints remained a problem. There appeared to be no dose escalation of omeprazole with time.

Research utilization among dental hygienists in Sweden--a national survey

Over the last decade evidence-based practice has become increasingly important in health care as an approach to improve patient outcomes. It is vital that dental hygienists, like other health professionals, use research findings to inform clinical practice. The objective of the present study was to investigate the extent of research utilization among dental hygienists in Sweden and to investigate the relationship between level of education and factors related to research utilization. A random sample of 261 dental hygienists in Sweden, 113 with 1 year and 148 with 2-year education, responded to a postal questionnaire covering various aspects of research utilization, i.e. their attitudes towards research, availability and support for the implementation of research findings, use of research in daily practice, their activity in seeking new research findings and their participation in a range of research-related activities. Dental hygienists with 2-year education had a more positive attitude towards research, used research to a greater extent and were more active in seeking new research findings than dental hygienists with 1-year education. Overall, relatively few dental hygienists reported that they implemented research findings in practice; the most frequently reported activity concerned reading research articles in professional journals. The conclusions are that the length of dental hygiene education is a key factor influencing the application of research findings to practice. One-year education appears to be inadequate to achieve evidence-based practice. Moreover, not even two years of formal education guarantees necessary competence in research for evidence-based dental hygiene practice.

Changes of gastric mucosal architecture during long-term omeprazole therapy: results of a randomized clinical trial

BACKGROUND

The impact of long-term acid suppression on the gastric mucosa remains controversial.

AIM

To report further observations on an established cohort of patients with gastro-oesophageal reflux disease, after 7 years of follow-up.

METHODS

Of the original cohort randomized to either antireflux surgery or omeprazole, 117 and 98 patients remained in the medical and surgical arms, respectively. Gastric biopsies were taken at baseline and throughout the study.

RESULTS

Fifty-three antireflux surgery and 39 omeprazole-treated patients had Helicobacter pylori infection at randomization. Eighty-three omeprazole-treated and 60 antireflux surgery patients remained H. pylori negative over the 7 years, and no change was observed in mucosal morphology except for a change in endocrine cell population (linear and diffuse hyperplasia, P = 0.03). During the 7-year study many patients, who were initially H. pylori infected, had the infection eradicated leaving only 13 omeprazole and 12 antireflux surgery patients still infected. In these patients, omeprazole induced a deterioration of the mucosal inflammation scores (P = 0.01) with a numerical increase of glandular atrophy.

CONCLUSIONS

Long-term omeprazole therapy does not alter the exocrine oxyntic mucosal morphology in H. pylori-negative patients, but mucosal endocrine cells appear to be under proliferative stimulation; in H. pylori-positive patients there are changes in mucosal inflammation and atrophy.

Mulligan bent leg raise technique--a preliminary randomized trial of immediate effects after a single intervention

The aim of this study was to investigate the effects over 24h, on range of motion and pain, of a single intervention of Mulligan's bent leg raise (BLR) technique in subjects with limited straight leg raise (SLR) and low back pain (LBP). Mulligan techniques are frequently used in practice but their effectiveness has not been adequately researched. Ninety-four subjects were contacted by telephone and 46 volunteered for assessment. Of these, 24 fulfilled inclusion criteria of unilateral SLR limitation and LBP. All subjects were naïve to physiotherapy, blinded, and randomly allocated to either a BLR (n=12) or placebo group (n=12). Range of SLR was measured by an assessor blind to group allocation, prior to, immediately following, and 24h after the intervention. Similarly pain was assessed prior to, and 24h after the intervention. After adjusting for differences in baseline values of SLR range, there was no difference between the two groups immediately after the intervention. However, 24h later, there was a significant increase in the range by 7 degrees in the BLR group, which may be clinically important. In addition there was a one-point reduction in pain, but no difference between groups. This preliminary study provides limited support for the use of the BLR technique; however, further research is required.

Functional consequences of stress-related suppression of adult hippocampal neurogenesis - a novel hypothesis on the neurobiology of burnout

BACKGROUND

Burnout is generally recognized as a work-related stress-induced condition associated with memory problems, fatigue, a sense of inadequacy, and depressed mood. Neurogenesis, the formation of new neurons in the human adult brain, provides a newly discovered dimension of brain plasticity.

OBJECTIVES

In a novel theory, we propose that the failure of adult hippocampal neurogenesis may provide the biological and cellular basis for altered brain plasticity in stress-related syndromes like burnout.

METHODS

A number of recent animal studies have shown that the rate of neurogenesis in the adult hippocampus may provide an important neurobiological correlate to the symptoms of stress.

RESULTS

As of yet, the normal physiological function of new neurons in the adult hippocampus remains unresolved although a number of studies and reviews indicate the importance of neurogenesis for memory and learning.

CONCLUSION

In line with this hypothesis, we propose burnout to be an exponent of stress-mediated decrease in adult neurogenesis leading to a decreased ability to cope with stress through decreased hippocampal function possibly involving a disturbed hippocampal regulation of the hypothalamo-pituitary-adrenal axis (HPA axis).

Identifying response to acid suppressive therapy in functional dyspepsia using a random starting day trial--is gastro-oesophageal reflux important?

BACKGROUND

Single subject trials offer an alternative approach to identify and characterize responders to a specific treatment.

AIM

To test a new single subject trials design, called random starting day trial, to identify acid-related symptoms in dyspepsia.

METHODS

A total of 119 patients with functional dyspepsia entered a 12-day, double-blind random starting day trial. All patients started on placebo and switched to omeprazole 80 mg/day at a randomized and blinded day between day 5 and day 9, with active treatment continuing for the rest of the trial. Based on changes of a daily symptom score, response was defined as a sustained > or =50% reduction of symptoms within 3 days of active treatment.

RESULTS

Thirteen of 119 patients (11%) were classified as spontaneous responders because of complete symptom relief before switching to omeprazole. Of the remaining 106 patients, 15 (15.6%) were classified as responders. Five of six (83%) responders compared with 28 of 53 (53%) non-responders had pathological reflux. Multivariate testing identified symptoms suggestive of gastro-oesophageal reflux predictive of response.

CONCLUSIONS

The random starting day trial design could identify a subset of dyspeptic patients with a uniform symptomatic response to acid-suppressive therapy. Response seems to be associated with gastro-oesophageal reflux. The random starting day trial needs to be further validated to be considered as a reliable instrument in clinical research.

Progress of unit based quality improvement: an evaluation of a support strategy

OBJECTIVE

To evaluate a strategy for supporting nurses to work with quality improvement (QI).

DESIGN

Post-intervention evaluation. Study participants and intervention: 240 nurses participated in a uniformly designed 4 day basic training course in applying a model for QI. Of these, 156 nurses from over 50 healthcare institutions constituted the generic education (GE) group while 84 nurses from 42 neonatal units took part in a project to develop national guidelines, constituting the targeted intervention (TI) group.

METHOD

Postal questionnaire 4 years after the training courses.

RESULTS

The response rate was 80% in the TI group and 64% in the GE group. Nurses in the TI group had a significantly higher rate in completing all phases of the QI cycle (p=0.0002). With no differences between the groups, 39% of all nurses were still involved in QI work 4 years after the training courses. Three factors were significantly related to nurses continuing their involvement in QI projects: remaining employed on the same unit (OR 11.3), taking courses in nursing science (OR 4.1), and maintenance of the same QI model (OR 3.1). Reported motives for remaining active in QI work were the enhancement of knowledge, influence over clinical practice, and development as a nurse. Reasons for discontinuation were organisational restructuring, a lack of facilitation and knowledge, and change of workplace.

CONCLUSIONS

Participation in a national guideline project, including a common focus for improvement, facilitation and opportunities for networking, seems to have enhanced the ability to carry out the process of QI, but not to sustain the QI work over a longer period.

Follow-up of acute pyelonephritis in children by Tc-99m DMSA scintigraphy: quantitative and qualitative assessment

PURPOSE

The author's goal was to create a system to identify children at risk for development of progressive renal damage.

METHODS

Thirty-four children were examined with Tc-99m DMSA scintigraphy in the acute stage of an initial episode of pyelonephritis, after 6 months, and again after 1 year. The scintigraphic findings were correlated with clinical and laboratory data.

RESULTS

All children had parenchymal defects in the acute stage: 93% of the kidneys and 85% bilaterally. After 6 months, the defects had diminished or disappeared in 66% of the kidneys. New defects appeared in 22%. At 1 year, no further improvement was seen in the kidneys, with an improved or unchanged pattern at 6 months. New defects appeared in 34%. Mean kidney activity uptake expressed as the percentage of administered dose (KU/AD), was low in the acute stage, increased at 6 months, with no further significant increase at 1 year. Eighty-three percent of children with urine cultures growing > or = 104 bacteria/ml at follow-up had decreased KU/AD values, whereas all children with urine cultures growing < 104 bacteria/ml had increased KU/AD values.

CONCLUSIONS

Quantitative assessment increases the sensitivity of Tc-99m DMSA scintigraphy. Follow-up with this method makes it possible to identify the children with decreasing renal tubular function who may be at risk for progressive renal damage. Moderate bacteruria of 104 bacteria/ml urine is associated with deterioration of renal tubular function.

National guidelines for Swedish neonatal nursing care: evaluation of clinical application

OBJECTIVE

To evaluate the clinical application of national guidelines for neonatal nursing.

DESIGN

Questionnaire survey.

SETTING

Thirty-nine neonatal care units in Sweden.

STUDY PARTICIPANTS

Thirty-five of 39 nurse managers at all Swedish neonatal care units.

INTERVENTION

Thirteen clinical guidelines for neonatal nursing care were presented in 1997. Recommendations on evidence-based nursing care and auditing measures were given. Most neonatal units in Sweden participated in the guideline development.

MAIN OUTCOME MEASURES

Extent of guideline application, ways in which the guidelines were used and perceived usefulness.

RESULTS

The guidelines were applied to different extents in 30 of the 35 units. Almost all the guidelines were applied, especially those covering general nursing care. In total, 72 Quality Improvement (QI) projects were reported, of which 51 concerned specific topics covered in the guidelines. Twenty units applied the guidelines as a starting point for QI. Four units evaluated nursing practice against the guidelines. Four factors [Dynamic Standard Setting System (DySSSy) as the QI method, > or = 4 years of practice as nurse manager, experience of nursing research, and good staff resources] were closely related to a more extensive application of the guidelines. Units with both a nurse manager and an assistant nurse manager were more likely to have used the guidelines as the basis for changing clinical practice.

CONCLUSIONS

The guidelines were successfully disseminated and diffused, but practitioner involvement in guideline development did not guarantee implementation. Downsizing, leadership and facilitation seemed to be crucial factors when getting evidence into practice. Limited occurrence of evaluations of clinical practice against guideline recommendations suggests a need for valid and user-friendly measures.

Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification

BACKGROUND

Endoscopic oesophageal changes are diagnostically helpful and identify patients exposed to the risk of disease chronicity. However, there is a serious lack of agreement about how to describe and classify the appearance of reflux oesophagitis

AIMS

To examine the reliability of criteria that describe the circumferential extent of mucosal breaks and to evaluate the functional and clinical correlates of patients with reflux disease whose oesophagitis was graded according to the Los Angeles system.

METHODS

Forty six endoscopists from different countries used a detailed worksheet to evaluate endoscopic video recordings from 22 patients with the full range of severity of reflux oesophagitis. In separate studies, Los Angeles system gradings were correlated with 24 hour oesophageal pH monitoring (178 patients), and with clinical trials of omeprazole treatment (277 patients).

RESULTS

Evaluation of circumferential extent of oesophagitis by the criterion of whether mucosal breaks extended between the tops of mucosal folds, gave acceptable agreement (mean kappa value 0.4) among observers. This approach is used in the Los Angeles system. An alternative approach of grouping the circumferential extent of mucosal breaks as occupying 0-25%, 26-50%, 51-75%, 76-99%, or 100% of the oesophageal circumference, gave unacceptably high interobserver variation (mean kappa values 0-0.15) for all but the lowest category of extent (mean kappa value 0.4). Severity of oesophageal acid exposure was significantly (p<0.001) related to the severity grade of oesophagitis. Preteatment oesophagitis grades A-C were related to heartburn severity (p<0.01), outcomes of omeprazole (10 mg daily) treatment (p<0.01), and the risk for symptom relapse off therapy over six months (p<0.05).

CONCLUSIONS

Results add further support to previous studies for the clinical utility of the Los Angeles system for endoscopic grading of oesophagitis.

Bile reflux into the esophagus. Bilitec 2000 measurements in normal subjects and in patients after Nissen fundoplication

BACKGROUND

Bilitec 2000 is a new spectrophotometric system that can detect bilirubin within the esophagus. The aim of this study was to test this new system in vitro and in vivo with special attention to patients operated on laparoscopically for gastroesophageal reflux with Nissen fundoplication.

METHODS

In vitro studies of gallbladder bile dilution curves at different pHs were performed with a combined pH and Bilitec probe and by investigation of the drift of the Bilitec system. In vivo studies were performed in 34 normal individuals and 12 patients operated on with a laparoscopic Nissen fundoplication. Intra/intervariations were evaluated in normal individuals.

RESULTS

The Bilitec system was able to detect changes in absorbance value within the range 0.14-0.6. Absorbance values were about 30% lower in an acid environment. The percentage of the total time with bile reflux was a median (range) of 3.9 (0-49.6) in normal individuals, with an intravariation within the intervariation, and 8.7 (0-36.6) in patients after a Nissen fundoplication. These values did not differ significantly. Eighty-two per cent of the normal subjects had some degree of bile reflux, if an absorbance value > or = 0.14 was accepted as the threshold value for the presence of bile reflux.

CONCLUSIONS

Bile reflux in normal individuals is frequent and not different from that in patients after a Nissen fundoplication. Surprisingly, the latter had bile reflux but no or minimal acid reflux. Factors other than bilirubin may interfere with the measurements.

Kidney size estimation in piglets using dimercaptosuccinic acid (DMSA) scintigraphy

The objective of this study was to validate kidney size measurements obtained by DMSA scintigraphy in kidneys of sizes relevant in paediatric practice. Kidney length, width and volume were measured by DMSA scintigraphy in 10 piglets in vivo and compared with measurements on excised kidneys using callipers, planar scintigraphy and submersion in water. In addition, a kidney phantom was constructed and placed in a torso phantom. The length, width and volume of the kidney phantom were compared with planar and tomographic scintigraphic measurements. The mean overestimation of kidney length by scintigraphy was 1.7% (+/- 1.2%) on excised kidneys and 3.9% (+/- 2.4%) in vivo. The corresponding figures for width measurements were 7.0% (+/- 3.9%) and 7.8% (+/- 4.4%). Tomography volume estimation overestimated the submersion volume by 23% (+/- 12%). Scintigraphic measurements on the phantom over-estimated length by 5%, width by 8% and volume by 11%. Scintigraphic renal length measurements are reliable and differ from the anatomical length by < 4% compared with excised kidneys and < 8% in vivo. Scintigraphic width measurements and volume estimations, especially on small kidneys, are less reliable.

Kidney swelling. Findings on DMSA scintigraphy

OBJECTIVE

To develop criteria identifying swollen kidneys on dimercaptosuccinic acid (DMSA) renal scintigraphy in acute pyelonephritis with regard to the DMSA distribution pattern, kidney functional size, and radioactive uptake.

SUBJECTS AND METHODS

Thirty-eight children aged 15 days to 7 years with known pyelonephritis were examined with DMSA renal scintigraphy. All children were observed 2 or 3 times. In total, 94 scintigrams were evaluated. Qualitative and quantitative criteria for swelling were defined.

RESULTS

Thirty-one observed kidneys satisfied the criteria of swelling. Quantitatively, kidney length and width/length were greater in swollen kidneys. Kidney uptake in percent of injected dose and kidney uptake/background were lower in swollen kidneys. Qualitatively, focal radioactive uptake defects known from a previous examination were sometimes obscured by swelling, and reappeared at follow-up. In 5 children with signs of swelling on repeat imaging, scintigraphy reinfection at the time of swelling was verified.

CONCLUSIONS

Swollen kidneys may be the only sign of acute pyelonephritis on DMSA scintigraphy and swelling may obscure focal radioactive uptake defects. Measurement of kidney size and radioactive uptake can help identify swollen kidneys at DMSA scintigraphy and disclose acute pyelonephritis in the absence of overt clinical symptoms.

The endoscopic assessment of esophagitis: a progress report on observer agreement

BACKGROUND & AIMS

The study and management of reflux esophagitis require an endoscopic classification system founded on esophageal lesions that can be reproducibly identified. The aim of this study was to investigate interobserver agreement for the identification of endoscopic lesions typical of reflux esophagitis.

METHODS

Paired comparisons of observers' descriptions were obtained. Seventeen endoscopists assessed 100 still images, and 42 endoscopists, including 13 endoscopists in training, assessed 23 endoscopic video recordings. In a third, ancillary study, using a simpler evaluation sheet, 219 gastroenterologists recorded their assessments of 20 still images.

RESULTS

The agreement between endoscopists was similar for still images and video recordings. Agreement between experienced endoscopists was acceptable to good for recognition of minimal changes (erythema, friability, mucosal edema; kappa = 0.46 to kappa = 0.8), mucosal breaks (discretely, demarcated areas of slough or erythema; kappa = 0.84), and complications (ulceration, kappa = 0.92; stricturing, kappa = 0.80; columnar metaplasia, kappa = 0.81), although there was poor agreement when the circumferential extent and number of mucosal breaks were assessed. However, total circumferential extent of the mucosal break had a kappa value of 0.59. Agreement between inexperienced endoscopists was poor for recognition of minimal changes but was good for recognition of complications (kappa, 0.70-0.90).

CONCLUSIONS

Endoscopists can identify mucosal breaks confined to a mucosal fold and lesions that extend throughout the esophageal circumference. Complications of reflux disease can be reproducibly recorded. Criteria for assessing the number of mucosal breaks and their radial extent must be defined more clearly, as must the features of minimal change esophagitis.

Potential cardioembolic sources in an elderly population without stroke. A transthoracic and transoesophageal echocardiographic study in randomly selected volunteers

Transoesophageal echocardiography renders a better image than transthoracic echocardiography of cardiac changes especially at the atrial level, and of atherosclerotic changes in the aorta. Although several studies on stroke patients have included transthoracic and transoesophageal echocardiography, the relevance of the reported findings remains unclear because of limited information on the prevalence of cardiac changes related to cardioembolism in a control population without stroke. In order to define a non-hospitalized group of volunteers without previous stroke or transient ischaemic attack, we randomly selected a group of 68 volunteers (mean age 65.4 years). These volunteers were divided into two groups: the elderly group, 65 years or older (n = 38) and the younger group, younger than 65 years (n = 30). The subjects underwent transthoracic and transoesophageal echocardiography, sonography of the carotid arteries, and magnetic resonance imaging of the brain. The prevalences of atrial septal aneurysm, patent foramen ovale, mitral annulus calcification, and protruding plaque in the aorta were investigated. We found atrial septal aneurysm in 13%, patent foramen ovale in 22%, protruding plaque in the aorta in 7%, and mitral annular calcification in 22% of the 68 subjects. No significant differences were found between the two age groups with the exception of mitral annular calcification, which was seen more often in the older group (P < 0.001). Total cardiac changes related to thromboembolism (including three cases with atrial fibrillation in the older group and other less common cardiac embolic sources) were more common in the older than in the younger group (23/38 vs 9/30; P < 0.05). If mitral annular calcification was excluded, no difference was found between the elderly and the younger group, 14/38 vs 8/30; ns. Even when subjects with a history of heart disease or a pathological ECG were omitted, no differences between the two age groups were found. The causal relationship between a possible embolic source and a clinical embolic event remains unsettled. The high prevalence of cardiac changes in a control population has to be considered when evaluating the significance of similar findings in patients with stroke.

Computer based quantitative analysis of capillary abnormalities in systemic sclerosis and its relation to plasma concentration of von Willebrand factor

OBJECTIVES

To evaluate an objective and quantitative method for assessment of capillary abnormalities in systemic sclerosis (SSc).

METHODS

Nailfold capillaries were investigated by capillary microscopy and photographed in 17 consecutive SSc patients (five with diffuse cutaneous systemic sclerosis (dSSc) and 12 with limited cutaneous systemic sclerosis (lSSc)) and in 17 healthy controls. Investigators having no access to clinical data made drawings from magnified projections of coded photographs and analysed them using a computer program. Capillary density (capillary loops/mm in the distal row) and median capillary loop area were calculated. Presence of functional or organic arterial changes was evaluated by measurement of finger pressure with finger cooling. Plasma concentration of von Willebrand factor (VWF) was analysed using an enzyme linked immunosorbent assay (ELISA).

RESULTS

In 16 of 17 SSc patients and 13 of 17 controls the technical quality of the photographs was sufficient for computer analysis. Capillary density was decreased in dSSc (median 6.9 loops/mm) and in lSSc (median 3.8 loops/mm) compared with healthy controls (8.9 loops/mm) and median capillary loop area was increased in dSSc (7.3 x 10(-3) mm2) and in lSSc (8.5 x 10(-3) mm2) compared with healthy controls (5.0 x 10(-3) mm2). An inverse relation was found between capillary density and median capillary loop area in SSc patients. Plasma VWF was increased in patients (median 401 IE/l in dSSc and 409 IE/l in lSSc) compared with controls matched for age and sex (median 276 IE/l). Computer based analysis showed capillary density below the control range and median capillary loop area above the control range in 14 of 16 SSc patients. Measurement of finger pressure with finger cooling showed organic vascular changes in nine of 13 SSc patients.

CONCLUSION

Computer based quantitative analysis has low interobserver variability and is a quantitative and sensitive method of assessing capillary abnormalities in SSc.

Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 2. Renal scarring and location of bacteriuria

OBJECTIVE

To evaluate the importance of refluxing versus anti-reflux ureteric implantation for the development of renal scarring in patients with a conduit or continent urinary diversion and for the incidence of bacteriuria in the upper urinary tract of patients with a conduit.

PATIENTS AND METHODS

Renal scintigraphy using 99mTc-dimercaptosuccinic acid was performed on 32 of 37 evaluable patients from a prospective, randomized study at a mean of 150 months (range 102-198) after urinary diversion. In five patients with a conduit diversion and unilateral renal scarring, urine was samples for culture from the proximal end of the conduit and from both renal pelvices by direct percutaneous aspiration.

RESULTS

Of 35 renal units (18 patients), studied after conduit diversion, scarring was found in 11 (two grade I, six grade II and three grade III) of 17 with refluxing anastomosis and in six (one grade I, four grade II and one grade III) of 18 with anti-reflux anastomosis (P = 0.06). Of 25 renal units (14 patients) after continent diversion, 16 showed scarring (seven grade I and nine grade II). Bacteriuria was found in four of five upper urinary tracts with a refluxing anastomosis, but in only one of five with an anti-reflux anastomosis. In these five patients scarring was present in all kidneys with refluxing anastomosis.

CONCLUSION

Anti-reflux ureteric anastomosis seems to be important for preventing scarring and bacteriuria in the upper urinary tract of patients with a conduit urinary diversion. Despite the anti-reflux technique of ureteric implantation, most patients with a continent reservoir had renal scarring, though it was generally less severe than in patients with a conduit urinary diversion.

Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 1. Glomerular filtration rate and patency of uretero-intestinal anastomosis

OBJECTIVE

To evaluate the glomerular filtration rate (GFR) and incidence of anastomotic stenosis in patients with urinary diversion by ileal or colonic conduit (refluxing or anti-reflux uretero-intestinal anastomosis) or with a continent caecal reservoir.

PATIENTS AND METHODS

All conduit urinary diversions performed from 1977 to 1984 were randomized by type (ileal or colonic) and by the method of ureteric implantation (with or without anti-reflux technique). In continent caecal reservoirs anti-reflux implantation was used for both ureters. Total and separate GFR were measured pre-operatively and after a mean follow-up of 123 months (range 36-198) with 51Cr-EDTA and scintillation renography.

RESULTS

Of the 56 evaluable patients, 18 had an ileal and 20 a colonic conduit, and 18 had a continent reservoir. The total mean GFR fell from 88 to 71 mL/min in the ileal group, from 84 to 65 mL/min in the colonic group and from 100 to 85 mL/min in the reservoir group. Separate GFR did not differ significantly between kidneys with and without reflux protection in the patients with a conduit diversion. Strictures occurred in 15 uretero-intestinal anastomoses and were unrelated to the mode of ureteric implantation (in the conduit groups). Renal function improved after ureteric reimplantation in six of seven kidneys, but after balloon dilatation in only one of five.

CONCLUSION

GFR fell moderately in all three groups, with no significant intergroup difference, and the continent caecal reservoir compared favourably with conduit diversion. The fall in separate GFR did not differ significantly between kidneys with and without reflux protection. Surgical exploration of uretero-intestinal stenosis is recommended if renal function is threatened.

Tc-99m DMSA renal scintigraphy during kidney maturation

A total of 282 renal scintigrams with Tc-99m DMSA in 238 children ranging in age from 10 days to 13 years performed during a 3-year period were reviewed. The authors present 94 kidneys in 85 children in whom no sign of pathology was demonstrated clinically, either by ultrasound or intravenous urography, or by micturating urethrocystography. By exploring homogeneity or heterogeneity of tracer distribution, kidney length, and background level, the authors were able to identify a "normal" pattern of tracer distribution according to age. They found that the average kidney length was 56 mm at birth, growing 1 mm per month during the first year of life, and 4 mm per year thereafter, until puberty. Average background activity was 14% of the average kidney activity at birth which decreased to approximately 6% during the first year of life, with no further decrease thereafter.

Carotid artery and heart disease in subtypes of cerebral infarction

BACKGROUND AND PURPOSE

The aim of the study was to determine the prevalences of carotid artery disease and major and minor potential cardioembolic sources (1) in patients with cerebral infarction and age-matched control subjects and (2) in different clinical subtypes of cerebral infarction.

METHODS

A series of 166 consecutive patients with cerebral infarction and 59 control subjects was examined. The study protocol included clinical subtyping of the cerebral infarctions, ultrasonography of the carotid arteries, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), ECG, and examination of the brain with computed tomography, magnetic resonance imaging, or autopsy.

RESULTS

Carotid artery stenosis > or = 80% or occlusion was present in 35 (21%) patients but in no control subjects (P < .001; chi 2 test). A major potential cardioembolic source was detected in 65 (39%) patients and 3 (5%) control subjects. Atrial fibrillation was present in 35 (21%) patients and 3 (5%) control subjects at initial ECG (P < .01) and in 47 (28%) patients at repeat examination; 17 patients had paroxysmal atrial fibrillation. Sinus rhythm and a major potential cardioembolic source were detected in 18 (11%) patients but in no control subjects (P < .01) at TTE (all patients and control subjects examined) or TEE (118 patients and 52 control subjects examined). The frequency of a minor potential cardioembolic source detectable at TTE or TEE was similar in the patient and control groups (51% and 53%, respectively [NS]) and increased significantly with age. A finding of carotid artery stenosis > or = 80% or occlusion, atrial fibrillation, or a major cardioembolic source detected at TTE or TEE was more frequent among patients with cortical symptoms from anterior or middle cerebral artery territories than among those with lacunar syndromes (66% versus 22%, respectively). The probable source of cerebral infarction was identified in most of the 166 patients: cardiac embolism in 28% of cases (n = 46), carotid artery disease in 8% (n = 14), both cardiac embolism and carotid artery disease in 7% (n = 11), and lacunar infarction in 23% (n = 38). In 57 (34%) of the patients no unequivocal cause of the cerebral infarction was found.

CONCLUSIONS

The prevalences of carotid artery and heart disease differ significantly between clinical subtypes of cerebral infarction. The cause of cerebral infarction remains uncertain in one third of patients. Because a minor potential cardioembolic source occurs in about 50% of both patients and control subjects, this finding is of questionable value as a risk factor for stroke in the elderly.

The significance of vesicoureteric reflux on kidney development assessed by dimercaptosuccinate renal scintigraphy

OBJECTIVE

To study the influence of vesicoureteric reflux on kidney parenchyma and renal length, and identify typical distribution patterns by dimercaptosuccinate (DMSA) renal scintigraphy.

PATIENTS AND METHODS

DMSA renal scintigraphies in 101 children (152 renal units) with vesicoureteric reflux grade 1-5 were reviewed.

RESULTS

Three main types of pathological DMSA patterns were found: (i) dysplasia; (ii) medial defect; and (iii) pole defects. In children with no history of pyelonephritis a normal distribution pattern was found in 31%, dysplasia in 23%, medial defect in 25%, pole defects in 17% and no typical pattern in 4%. In those with a history of pyelonephritis a normal distribution pattern was found in 28%, dysplasia in 24%, medial defect in 21%, pole defects in 24% and no typical pattern in 3%. A normal pattern was significantly more frequent in kidneys with reflux grade 1-2. Dysplasia was significantly more frequent in kidneys with reflux grade 4-5. In children with no history of pyelonephritis 42% of the renal units had reduced length, 8% with no other sign of pathology. The frequency of reduced kidney length at reflux grade 1-2 did not differ significantly from that at higher grades of reflux. In children with a history of pyelonephritis 52% of the renal units had reduced length, 13% with no other sign of pathology. The frequency of reduced kidney length with a normal DMSA pattern did not differ significantly from that with a pathological pattern.

CONCLUSION

The pathological DMSA distribution with vesicoureteric reflux generally conforms to one of three main patterns. Reduced kidney length is frequent even at lower grades of vesicoureteric reflux even in patients with no history of pyelonephritis, and can be the only sign of pathology.

Cerebral lesions on magnetic resonance imaging, heart disease, and vascular risk factors in subjects without stroke. A population-based study

BACKGROUND AND PURPOSE

To assess the prevalence of asymptomatic abnormalities on magnetic resonance imaging of the brain and their possible relation to hypertension, heart disease, and carotid artery disease, we studied 77 randomly selected subjects (mean age, 65.1 years; range, 36 to 95 years) with no history of focal brain lesions.

METHODS

The study protocol included magnetic resonance imaging of the brain, transthoracic and transesophageal echocardiography, ultrasonography of the carotid arteries, and electrocardiographic recording. Deep and periventricular white matter hyperintensities on magnetic resonance imaging were assessed both separately and together.

RESULTS

On magnetic resonance imaging of the brain 62.3% (95% confidence interval [CI], 51.5% to 73.2%) of the subjects had white matter hyperintensities. These abnormalities increased significantly with age (chi 2 test; P = .0001), from 13.6% (95% CI, 0% to 28.0%) of subjects aged younger than 55 years to 85.2% (95% CI, 71.8% to 98.6%) of subjects aged 75 years or older. Six subjects had deep gray matter hyperintensities localized in the basal ganglia, and one had a cerebellar infarction. Stepwise logistic regression analysis identified age and a history of heart disease (but not echocardiographic findings) to be independently associated with deep and periventricular white matter hyperintensities. Hypertension was only independently associated with periventricular white matter hyperintensities. Of the 68 subjects examined with both transthoracic and transesophageal echocardiography, potential cardioembolic sources were detected in 38.2% (95% CI, 26.7% to 49.8%) of the subjects with transthoracic echocardiography and in 47.1% (95% CI, 35.2% to 58.9%) of those with transthoracic and transesophageal echocardiography combined. In subjects aged 75 years or older, a possible cardiac embolic source was detected in 64.0% on transthoracic echocardiography and in 72.0% on transthoracic and transesophageal echocardiography combined, compared with 5.3% and 15.8%, respectively, in subjects aged younger than 55 years.

CONCLUSIONS

White matter hyperintensities and potential cardioembolic sources are frequently present in asymptomatic individuals, stressing the need for age-matched control subjects in studies of patients with stroke or dementia.

Typical technetium dimercaptosuccinic acid distribution patterns in acute pyelonephritis

Technetium dimercaptosuccinic acid renal scintiscans in 37 children with clinical diagnosis of acute pyelonephritis were reviewed. In 18 children, follow-up scintigraphy was obtained after an interval ranging from 5 to 8 months. Uptake abnormalities were found in 89% of the children (74% of the kidneys). We were able to identify four typical pathological uptake patterns: (i) pole defect(s), usually wedge shaped (60%); (ii) lateral wedge shaped defect (4%); (ii) scattered multiple defects (21%); and (iv) swollen kidney without areas of diminished uptake (15%). Remaining pathology at follow-up was found in 52% of the kidneys. Vesicoureteric reflux was present in 33% of the children with scintigraphic signs of pyelonephritis. Frequencies of parenchymal changes in the acute phase and at follow-up were not significantly correlated to the presence of reflux.

DMSA scintigraphy in renal duplex system

During a 4-year period 40 children (13 boys and 27 girls) with renal duplex system were examined with DMSA scintigraphy. The age at the investigation varied from 18 days to 9 years, mean 2.5 years. Duplicated system existed in 52 kidneys, bilaterally in 12 cases, right-sided in 10 and left-sided in 18 cases. The renal DMSA scintigraphy of the 52 duplicated kidneys revealed insignificant parenchymal damage in 19 kidneys. Moderate parenchymal damage existed in 10 kidneys. In the remaining 23 kidneys, severely deteriorated function of the upper moiety was found in 15 cases and of the lower pole in 9 cases, as both moieties were affected in one kidney. The function of the severely deteriorated moiety varied between 0% and 14%, mean 5.7% of the total renal function. All the 23 cases with severely deteriorated function were operated upon, 22 with heminephrectomy and one with nephrectomy. The assessment of parenchymal function of the separate parts of the kidney with duplex system by DMSA scintigraphy is of great value in the decision of management and surgical procedure.

Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach

Patients with nonspecific mechanical low back pain (n = 103), examined by an orthopaedic surgeon and a social worker, were randomized to an activity group (n = 51) and a control group (n = 52). Patients with defined orthopaedic, medical, or psychiatric diagnoses were excluded before randomization. No patients were excluded due to place of birth or difficulties in speaking or understanding the Swedish language. The purpose of the study was to compare mobility, strength and fitness after traditional care and after traditional care plus a graded activity program with a behavioral therapy approach. A graded activity program, with a behavioral therapy approach was given under the guidance of a physical therapist. The endpoint of the graded activity program was return to work. This program significantly increased mobility, strength, and fitness more than could be explained by only a time recovery effect, especially in males. The patients in the activity group returned to work earlier than did the patients in the control group. Spinal rotation, abdominal muscle endurance time and lifting capacity were significantly correlated to rate of return to work. Traditional care plus a graded activity program were superior to only traditional care, evaluated in terms of mobility, strength and fitness. The graded activity program proved to be a successful method of restoring occupational function and facilitating return to work in subacute low back pain patients. The patients in the graded activity program learned that it is safe to move, while regaining function.

The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach

The aim of this study was to determine whether graded activity restored occupational function in industrial blue-collar workers who were sick-listed for 8 weeks because of subacute, nonspecific, mechanical low back pain (LBP). Patients with LBP, who had been examined by an orthopedic surgeon and a social worker, were randomly assigned to either an activity group (n = 51) or a control group (n = 52). Patients with defined orthopedic, medical, or psychiatric diagnoses were excluded before randomization. The graded activity program consisted of four parts: (1) measurements of functional capacity; (2) a work-place visit; (3) back school education; and (4) an individual, submaximal, gradually increased exercise program, with an operant-conditioning behavioral approach, based on the results of the tests and the demands of the patient's work. Records of the amount of sick leave taken over a 3-year period (ie, the 1-year periods before, during, and after intervention) were obtained from each patient's Social Insurance Office. The patients in the activity group returned to work significantly earlier than did the patients in the control group. The median number of physical therapist appointments before return to work was 5, and the average number of appointments was 10.7 (SD = 12.3). The average duration of sick leave attributable to LBP during the second follow-up year was 12.1 weeks (SD = 18.4) in the activity group and 19.6 weeks (SD = 20.7) in the control group. Four patients in the control group and 1 patient in the activity group received permanent disability pensions. The graded activity program made the patients occupationally functional again, as measured by return to work and significantly reduced long-term sick leave.

Ambulatory 23 hour recording of intraoesophageal pressures in normal volunteers: a propagation analysis from one proximal and two distal recording sites

pH data were obtained from one level and pressure data from three levels in the oesophagus over 23 hours in 24 healthy volunteers, followed by automatic propagation analysis of motility data and analysis of time with pH less than 4. Apart from periods of meal ingestion, isolated pressure complexes were found more frequently in the distal than in the proximal oesophagus. This was especially common in the recumbent position at night. Most contractions of the proximal oesophagus were propagating. In the distal oesophagus were propagating. In the distal oesophagus propagating pressure waves were more frequent during the day than during the night and most frequent during meals. The state of consciousness rather than body position per se is important in determining the frequency of simultaneous contractions in the distal oesophagus.

Twelve hour overnight oesophageal pH monitoring in patients with reflux symptoms

Results of continuous 12 hour overnight pH monitoring (duration of pH less than 4) were reviewed in 112 patients with heartburn or regurgitation, or both, and in 56 normal subjects. Patients had more reflux than normal subjects. Medically controlled patients (n = 51) had less acid reflux than patients who subsequently underwent reflux surgery (n = 61), but there was a considerable overlap between those two groups. Surgery was followed by a reduction in acid reflux to a value similar to that in normal subjects. Patients in whom surgery was deemed to have failed had more reflux after the operation than those in whom it was successful, but no difference could be found in the preoperative reflux values of these two subgroups. Monitoring pH is not of value in selecting candidates for surgery since the results are not a good predictor of outcome, but it is useful in the objective evaluation of surgical results.