Patient motivations for seeking online therapy for binge eating disorder

Introduction

Binge Eating Disorder (BED) is characterized by repeatedly losing control over eating behavior and consuming large amounts of food within a short period of time. In later years, a growing body of evidence for effectiveness of internet-based Cognitive Behavioral Therapy (iCBT) as treatment for BED has emerged. Regarding the ability to complete a self-help program on the internet, internal self-regulation can be viewed as important.

Objectives

To qualitatively explore patient motivations for seeking therapy for BED according to intrinsic and extrinsic motivation as well as patient reasons for seeking online therapy.

Methods

The research design of this study was qualitatively. The participants were 52 adults suffering from mild to moderate BED. Data consisted of written texts entered by the participants into the online therapy program. The texts addressed the participants’ goals for their treatment course and their motives for seeking online therapy. The texts were analyzed by the means of systematic text condensation.

Results

Pertaining patient motivations for seeking therapy for BED, five main motivations that reached a saturated level in the sample were discovered: wish for control; avoidance of guilt/shame; desire for tools/insights; weight loss; and psychological stress. Participants ranged from one motivational factor to four, no participant had all the motivational factors. Regarding patient reasons for seeking online therapy, the following themes including sub themes were found: online treatment, treatment at home, and flexible treatment.

Conclusions

The results indicate that online therapy for BED may be able to breach some of the barriers there are towards treatment seeking.

Virtual reality-based exposure with applied biofeedback for social anxiety disorder

Introduction

Social Anxiety Disorder (SAD) is considered the most prevalent anxiety disorder with the highest disease burden amongst anxiety disorders. Despite available effective treatment with Cognitive Behavioral Therapy, a majority of individuals with SAD do not seek treatment and many drop out when confronted with elements of exposure. Several studies highlight the many advantages virtual reality exposure holds over in vivo exposure. In this study, we investigate the added effect of real-time biofeedback during virtual reality exposure.

Objectives

The current study is part of a large scale study called VR8. The current study aims to develop and evaluate the feasibility of a VR-biofeedback-intervention for adults with mild to severe social anxiety disorder, before continuing randomized controlled trials.

Methods

Data from semi-structured interviews and surveys will be compared to biodata collected during VR exposure. Participants include a minimum of (n=10) patients and (n=10) clinicians from the Mental Health Services in the Region of Southern Denmark. Surveys include questionnaires used for assessment of anxiety symptoms, usability of technology, and presence in the virtual environment. Collected biodata includes heart rate variability and electrodermal activity. Behavioral markers include eye-gaze. The findings will be analyzed and discussed in a mixed methods design.

Results

The study is ongoing. Preliminary results will be available at presentation.

Conclusions

Successful development and implementation of a biofeedback-informed virtual reality exposure intervention may provide increased reach for patients and individuals who would have otherwise not sought- or dropped out of regular treatment, as well as inform the clinician on how to proceed during virtual exposure.

Conflict of interest

Prof. Stephané Bouchard is consultant to and own equity in Cliniques et Développement In Virtuo, which develops virtual environments, and conflicts of interests are managed according to UQO’s conflict of interests policy; however, Cliniques et Développeme

Monitowapplication – an investigation of the usability during the first 18 months of commissioning in practice

Introduction

In cognitive behavioral treatment of anxiety disorders, registration of emotions and behavior is an important part of the intervention. Normally, paper and pencil is used but registrations on a mobile application such as MONARCA may be a useful alternative.

Objectives

This study investigates the usability of MONARCA during the first 18 months of commissioning in practice.

Methods

To explore the usability, semi-structured interviews were conducted with seven patients and three therapists, combined with data from a survey questionnaire where 10 patients and 12 therapists rated the usability of the app on the System Usability Scale. Participants were recruited from an outpatient clinic for affective disorders in The Mental Health Services in the Region of Southern Denmark.

Results

Technical performance, time allocation, therapist effort, commitment, enthusiasm, and increased knowledge are imperative factors. Therapists and patients found that the benefits of registering emotions and behaviors on a mobile application were that it was easy for patients to remember to register daily, it was easy to gain an overview over symptom progress, and access to the registrations improved therapist’s ability to prepare sessions.

Conclusions

Overall, the results from the interviews and survey indicated that both patients and therapists found MONARCA useful, but several improvement opportunities regarding application features and use in the treatment course were found.

Disclosure

No significant relationships.

A Method to Estimate Brain Volume from Head CT Images and Application to Detect Brain Atrophy in Alzheimer Disease

BACKGROUND AND PURPOSE

Total brain volume and total intracranial volume are important measures for assessing whole-brain atrophy in Alzheimer disease, dementia, and other neurodegenerative diseases. Unlike MR imaging, which has a number of well-validated fully-automated methods, only a handful of methods segment CT images. Available methods either use enhanced CT, do not estimate both volumes, or require formal validation. Reliable computation of total brain volume and total intracranial volume from CT is needed because head CTs are more widely used than head MRIs in the clinical setting. We present an automated head CT segmentation method (CTseg) to estimate total brain volume and total intracranial volume.

MATERIALS AND METHODS

CTseg adapts a widely used brain MR imaging segmentation method from the Statistical Parametric Mapping toolbox using a CT-based template for initial registration. CTseg was tested and validated using head CT images from a clinical archive.

RESULTS

CTseg showed excellent agreement with 20 manually segmented head CTs. The intraclass correlation was 0.97 (P < .001) for total intracranial volume and 0.94 (P < .001) for total brain volume. When CTseg was applied to a cross-sectional Alzheimer disease dataset (58 with Alzheimer disease patients and 58 matched controls), CTseg detected a loss in percentage total brain volume (as a percentage of total intracranial volume) with age (P < .001) as well as a group difference between patients with Alzheimer disease and controls (P < .01). We observed similar results when total brain volume was modeled with total intracranial volume as a confounding variable.

CONCLUSIONS

In current clinical practice, brain atrophy is assessed by inaccurate and subjective "eyeballing" of CT images. Manual segmentation of head CT images is prohibitively arduous and time-consuming. CTseg can potentially help clinicians to automatically measure total brain volume and detect and track atrophy in neurodegenerative diseases. In addition, CTseg can be applied to large clinical archives for a variety of research studies.

Exercise addiction: Links, risks and challenges faced

Introduction

Exercise addiction is a condition described by a craving for physical training resulting in excessive exercise behaviour and withdrawal symptoms. It has not been accepted as a mental disorder and further research is needed to examine the pathology of the condition.

Objectives

Exercise addiction is suggested to have links to other mental disorders and risks in terms of negative consequences such as injuries. Treatment for exercise addiction faces several challenges as the condition is associated with ambivalence, and studies based on controlled interventions are missing.

Aims

The aim of this study was to examine and interpret the existing research on links, risks and challenges faced in treatment interventions.

Methods

A literature review was conducted in the databases PubMed, PsycINFO and Scopus with the terms: “exercise addiction, excessive exercise” and/or “comorbidity, eating disorder, depression, anxiety, personality, pain, injury, illness, social isolation, stress, intervention, treatment”.

Results

Exercise addiction seems to be associated with eating disorder pathology, obsessive-compulsive behaviour and personality traits characterized by perfectionism, narcissism and neuroticism. Overload injuries (e.g. stress fractures) and impaired interpersonal relations are reported. In a treatment context, low compliance is described as a challenge. Thus, motivational interviewing is recommended, and also cognitive behavioural therapy is suggested for treatment. None of these interventions have yet been scientifically evaluated in addicted exercisers.

Conclusion

This review concludes that exercise addiction has links to psychopathology and increases the risk of injuries. More research is needed to estimate the level of psychosocial and physiological distress in these athletes. Controlled treatment interventions have to be conducted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Exercise addicts with injuries are in risk of depression

Introduction

Exercise addiction is characterized by increasing exercise amounts, withdrawal symptoms and lack of control. Exercisers with addiction continue to exercise in spite of pain and injury because they use exercise to regulate emotions, identity and self-esteem. How do they react to injuries?

Objectives

It is hypothesized that exercise addiction is a risk factor for emotional distress when an injury occur due to withdrawal symptoms and lack of identity.

Aims

To estimate the prevalence of exercise addiction in exercisers with injuries at the musculoskeletal system and to test the relationship between addiction and emotional distress (depression and stress).

Methods

The Exercise Addiction Inventory was used to identify exercise addiction. To measure depression and stress we used the Major Depression Inventory (MDI) and the Perceived Stress Scale (PSS). Participants (n = 694) were regular exercisers with injuries at foot, knee or shoulder at an orthopedic hospital department.

Results

The prevalence of exercise addiction was 7.6%. We found that exercisers with addiction reported more emotional distress in terms of higher MDI-scores 18.0 (SD = 11.0) versus 11.7 (SD = 9.1); P = 0.00 and in total PSS-score 17.6 (SD = 7.2) versus 13.9 (SD = 6.8); P = 0.00. Chi2 analyses showed that 25% of the addicted exercisers met the criteria for clinical depression, while only 11% of the non-addicted exercisers were depressed; P = 0.00.

Conclusions

Exercisers with addiction appear at somatic departments treating musculoskeletal injuries. It is a vulnerable group characterized by elevated levels of depressive symptoms and clinical stress. We recommend to offer psychological interventions focusing on emotional distress and prevention of re-injury by reducing excessive and obsessive exercise patterns.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Therapeutic potency of IL2-caspase 3 targeted treatment in a murine experimental model of inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) comprises primarily the two disorders - ulcerative colitis and Crohn's disease - that involve deregulated T cell responses. The ever-increasing incidence rate of Crohn's disease and ulcerative colitis during recent decades, combined with the limited efficacy and potential adverse effects of current treatments, explain the real need for seeking more specific and selective methods for treating these diseases.

AIM

To investigate the ability of interleukin 2 (IL2)-caspase 3 chimeric protein, designed to target activated T lymphocytes that express the high-affinity IL2 receptor, to ameliorate the clinical symptoms of acute murine experimental colitis, using a mouse model of dextran sodium sulfate (DSS)-induced colitis.

METHODS

Mice with DSS-induced colitis were treated with IL2-caspase 3 for 7 days and disease severity was assessed in parallel to control, non-treated mice, receiving only daily injections of phosphate-buffered saline. IL2-caspase 3 was tested both for its ability to prevent the development of colitis, and for its therapeutic potential to cure on-going, active acute disease. In addition, colon tissue samples were used for myeloperoxidase assays and RNA isolation followed by polymerase chain reaction to determine mRNA expression levels of specific genes.

RESULTS

Treatment with IL2-caspase 3 dose-dependently ameliorated the disease activity index (DAI) of mice colitis. We achieved up to 78% improvement in DAI with intravenous injections of 15 microg/mouse/day. Furthermore, IL2-caspase 3 decreased neutrophil and macrophage infiltration to the inflamed tissue by up to 57%. IL2-caspase 3 was proven as a therapeutic reagent in another model, where treatment begins only after disease onset. Here we demonstrated a 70% decrease in DAI when compared to non-treated sick mice. A reduction in mRNA expression levels of both IL1 beta and tumour necrosis factor alpha was found in lysates of total colon tissue of treated mice, as compared to sick, untreated mice. We also found that expression levels of Bcl2 were significantly decreased after treatment, while Bax was upregulated in comparison to non-treated mice. Moreover, the Bcl2/Bax ratio, which is elevated in both experimental colitis and in human Crohn's disease, decreased dramatically after treatment.

CONCLUSIONS

IL2-caspase 3 chimeric protein may provide a novel approach to the therapy of human IBD, and a possible suggested treatment for other pathological conditions that involve uncontrolled expansion of activated T cells.

Distal infantile neuroaxonal dystrophy--a new familial variant with perineuronal argyrophilic bodies

We report on two sisters with an infantile onset of dyskinetic movements, tonic spasms, seizures and apneic spells. The condition deteriorated to a hypotonic "burnt out" stage by the age of 3 years in the older sister and to a stable dyskinetic condition by the age of 2.5 years in the younger one. A skin biopsy from the older sister revealed myelinated nerve fibers crowded with neurofilaments. The extensive investigation for neurometabolic disorder, magnetic resonance imaging of the brain, and ophthalmological and neurophysiological examinations were not especially revealing. The older sister died at the age of 3 years. The autopsy revealed no apparent loss of nerve cells in the brain and no sign of storage disease. However, silver-stained coarse granules, immunopositive for neurofilament polypeptide, were found around nerve cell bodies in the cortex and in the basal ganglia. Electron microscopy revealed perineuronal membrane-bound profiles filled with filaments. Silver-stained axonal torpedoes were found in the cerebellum, but there were no spheroids. The substantia nigra, the locus ceruleus and the nucleus basalis of Meynert showed extensive perineuronal and perivascular swelling. Homovanillic acid was severely reduced, while 5-hydroxyindoleacetic acid and hydroxymethylphenyl glycol were normal in the cerebrospinal fluid of the severely affected, autopsied case. The two cases are considered to represent a new form of infantile neuroaxonal dystrophy, characterized by the degeneration of perineuronal terminals in the cerebral cortex and in the basal ganglia, as well as by axonal degeneration in the cerebellum and peripheral nerves.

Combined magnetic resonance imaging and single-photon emission tomography scanning in the discrimination of Alzheimer's disease from age-matched controls

OBJECTIVE

To compare the utility of temporal lobe magnetic resonance imaging (MRI) and single-photon emission tomography (SPET) scanning in discriminating between subjects with Alzheimer's disease (AD) and age-matched controls.

METHODS

Thirty subjects with NINCDS-ADRDA AD (23 probable AD, 5 possible AD, 2 definite AD) and 22 age- and sex-matched controls underwent T1-weighted coronal MRI scanning (0.3 T) and technetium 99m-HMPAO SPET scanning. MRI scans were analyzed using a digitizer system with volumes of hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus, and whole cerebral cortex calculated. From SPET scans, regional cerebral blood flow (rCBF) was assessed in anterior and posterior frontal, parietal, occipital, and mesial temporal cortex using a region of interest analysis with the cerebellum as a reference area.

RESULTS

Using MRI, the areas that best separated groups were left hippocampal and left amygdala volume, resulting in correct classification (patient vs. control) in 79% of cases (sensitivity 77%, specificity 82%). Exactly the same proportion of subjects were correctly classified by SPET, with the most discriminating rCBF changes being left parietal and right posterior frontal. Combining information from both scans improved the proportion of correctly classified subjects in a discriminant function to 90% (sensitivity 93%, specificity 86%; only 2 AD and 3 controls misclassified). All AD subjects had abnormalities on MRI and/or SPET (sensitivity for combined examinations 100%), while abnormalities on both MRI and SPET had a positive predictive value of 100% for dementia (including the detection of one control subject who later had dementia). Significant correlations between MRI and SPET measures were seen in control subjects but not in patients.

CONCLUSION

Both 0.3 T MRI and single rotating gamma camera SPET were equally useful in separating AD subjects from age-matched controls, although the combination of both significantly enhanced discrimination. In particular, all AD subjects had abnormalities on either MRI or SPET and both techniques may have an important role in assisting with clinical diagnosis, though replication in other centers and examination of differentiation of AD from other causes of dementia need to be examined.

Comparison of MRI perfusion imaging and single photon emission computed tomography in chronic stroke

There have been few direct comparisons between MR perfusion-weighted imaging (PWI) and established perfusion imaging techniques, and none in chronic stroke. We therefore studied 17 chronic hemispheric infarction patients (mean, 90 days) and compared hypoperfusion volumes determined from PWI maps of relative cerebral blood flow (rCBF) and volume (rCBV), and mean transit time (rMTT) with those measured with (99)Tc-HMPAO single photon emission computed tomography (SPECT). Comparisons were also made between infarct size (T(2)-WI) and clinical scales. Correlations were found between lesion location and volume in all three PWI hemodynamic parameter maps with clinical state and lesions on SPECT and T(2)-WI. In 3 patients, rCBF and rCBV lesions extended well beyond the borders of moderate-sized infarctions. We conclude that in chronic stroke, PWI can delineate regions of abnormal perfusion that reflect the degree of functional impairment and structural damage. The finding of peri-infarct hypoperfusion suggests that PWI may have the potential to provide a rapid and non-invasive template against which interventional strategies aimed at promoting functional recovery may be investigated.

Lower body function and mortality in Mexican American elderly people

BACKGROUND

The purpose of this analysis was to examine the differential impact of performance-based and self-reported lower body measures on 2-year mortality in Mexican American elderly persons.

METHODS

Data employed are from the Hispanic Established Population for Epidemiological Studies of the Elderly, a probability survey of 3050 community-dwelling Mexican Americans aged 65 and older from the five Southwestern states interviewed in 1993 and 1994. Of the baseline sample with complete data, 198 persons were confirmed deceased 2 years later. A three-task, performance-based, lower body function measure consisting of a short walk, balance, and repeated chair stands tests was used. Self-reported lower body function was measured by a 4-item Activities of Daily Living (ADL) measure involving the lower body.

RESULTS

The three-task, lower body function measure was a significant predictor of 2-year mortality. The short walk alone was as predictive as the summary measure. The predictive ability of both measures was minimally reduced by the inclusion of the self-reported ADL measure and life-threatening medical conditions. Finally, the ADL measure was not a significant predictor of mortality with all the other variables in the analysis.

CONCLUSION

Objective measures of lower body function were significant predicators of mortality in Mexican American elderly persons, as found in the general population. Unlike previous studies, the ADL measure was not an independent predictor of mortality after controlling for the objective measure and other risk factors. Additional research is needed to address why objective measures of function are such strong predictors of death.

Control of nuclear export of hnRNP A1

mRNA export is mediated by RNA-binding proteins which shuttle between the nucleus and cytoplasm. Using an in vitro unidirectional export assay, we observe that the shuttling mRNA-binding protein, hnRNP A1, is exported only extremely slowly unless incubations are supplemented with snRNA-specific oligonucleotides which inhibit splicing. In vivo microinjection experiments support this conclusion. Like many examples of nucleocytoplasmic transport, export of hnRNP A1 requires energy and is sensitive to the presence of wheat germ agglutinin. It does not, however, require supplementation with cytoplasmic proteins. Although the exportin, Crm1, is needed for export of several varieties of RNA, both the in vitro assay and in vivo assays show that it is not required for export of hnRNP A1. In vitro and in vivo studies also show that inhibition of transcription allows continued shuttling of hnRNP A1 and in fact accelerates its export. Judging from the stimulatory effects of targeted destruction of snRNAs, this is likely to reflect completion of the covalent maturation of the RNAs with which hnRNP A1 associates. These observations therefore provide a simple explanation of why multiple RNA-binding proteins relocate to the cytoplasm upon inhibition of transcription in vivo.

High incidence of micrometastases in breast cancer sentinel nodes

BACKGROUND

Sentinel lymph node biopsy (SLNB) is being investigated as an alternative to formal axillary dissection in early breast cancer. Avoiding the morbidity of unnecessary axillary dissection is seen as the main potential benefit of SLNB. Sentinel lymph node biopsy also allows enhanced pathological analysis. A series of 62 sentinel node (SN) biopsies demonstrating a high incidence of micrometastases is presented here.

METHODS

All SN were initially examined and reported by H&E staining. All negative SN were analysed after staining with polyclonal anticytokeratin antibody.

RESULTS

Sixty-two patients underwent SLNB at Royal Melbourne Hospital between May 1998 and February 2000. One or more SN was identified in 51/62 patients. A total of 10/51 contained metastases identified after H&E staining. There was one false negative. A total of 10/41 patients with H&E-negative SN had micrometastases identified on immunohistochemistry (IHC). Micrometastases were more common in patients with larger tumours, with disease found in the H&E-negative SN of 1/17 T1a and T1b (1-10 mm), 4/15 T1c (11-20 mm), and 5/9 T2 (20-50 mm) tumours.

CONCLUSION

Sentinel lymph node biopsy can accurately assess the axilla in most patients with early breast cancer. A significant proportion of histologically negative SN will have micrometastases identifiable with IHC. Although the clinical significance of such metastases is uncertain, the available evidence suggests that these patients have a poorer prognosis than other patients with negative lymph nodes.

Review: dynamic stability of the interphase nucleus in health and disease

Ongoing export of newly synthesized RNAs, as well as control of transcriptional activity, involves dynamic nucleocytoplasmic transport of proteins. Some proteins that shuttle reside primarily in the nucleus while others are concentrated in the cytoplasm. Moreover, some proteins shuttle continuously, while others shuttle only once. A third group is stimulated to relocate either into or out of the nucleus as a result of interruption of shuttling. In addition to these protein-specific events, several physiological stimuli have global effects on nucleocytoplasmic transport. In related events, selected proteins move between distinct sites in the nucleoplasm, others enter and leave the nucleolus, and still others transit between the nuclear envelope and cytoplasmic membranes. These multiple dynamic distributions provide numerous opportunities for precise communication between spatially distant sites in the cell.

Hearing problems in Mexican American elderly

OBJECTIVE

To investigate hearing problems in a sample of elderly Mexican Americans.

STUDY DESIGN

A longitudinal field study of a cohort of 3,050 subjects with in-person baseline and a 2-year follow-up. Population-based, cross-sectional, weighted data were analyzed.

SETTINGS AND SUBJECTS

Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) consisting of Mexican Americans aged 65 and older provided basic health data using area probability sampling in five southwestern states during 1993 and 1994.

MAIN OUTCOME MEASURES

Information was collected regarding demographics, medical conditions, smoking, and alcohol consumption. Hearing problems were identified through a series of self-perceived hearing problem questions, hearing aid use, and inability to hear a normal voice.

RESULTS

A hearing problem was identified in 24.5% of this cohort (weighted, 748/3,049). Statistical analysis using a multiple logistic regression model was performed to identify factors jointly associated with hearing problems. Age group (odds ratio [OR] = 2.7, p<0.0001), male sex (OR = 1.9, p< 0.0001), hypertension (OR = 1.4, p<0.001), arthritis (OR = 1.5, p<0.0005), significant depressive symptomatology (OR = 1.4, p<0.002), and ever having consumed alcohol (OR = 1.4, p<0.005) were jointly statistically significantly associated with hearing problems. Number of cigarettes smoked daily (e.g., 0, 1-10, 11-20, etc.) was nearly significantly associated with a hearing problem in the multivariate model (OR = 1.1 for each increased in category, p<0.07).

CONCLUSIONS

Hearing problems are common in this population. Control of hypertension, an amelioration of arthritis, and decreasing the consumption of alcohol and cigarettes may lower the likelihood of development of a hearing problem. Initial depressive symptomatology may have occurred subsequent to the hearing loss. A longitudinal study would allow determination of the direction of causation.

Treatment-resistant schizophrenia and staff rejection

This study examined the relationship between characteristics of patients suffering from treatment-refractory schizophrenia and staff rejection and criticism. Subjects were 30 inpatients with treatment-resistant schizophrenia and the 29 staff members treating them. Measures included assessment of the patients' symptoms and aggression risk profile using the Positive and Negative Syndrome Scale (PANSS) and assessment of staff attitudes toward these patients using the Patient Rejection Scale (PRS). Nursing staff completed the Nurses' Observation Scale for Inpatient Evaluation (NOSIE). PRS ratings did not correlate with patients' demographic and treatment characteristics. Significant correlations existed, however, between increased staff rejection and higher scores for PANSS cognitive factor and NOSIE manifest psychosis factor. Negative symptoms, although preponderant in the patient sample, were not significant predictors of staff rejection on the PRS. Older nursing staff tended to view patients as more irritable and manifestly psychotic. These findings suggest that disorganized behavior and impaired cognition dysfunction areas are more likely to be associated with high levels of rejection among staff working with treatment-resistant schizophrenia patients. Incorporation of the relatively new concepts of cognitive dysfunction and treatment resistance in staff training programs and multidisciplinary team reviews may greatly benefit schizophrenia patients and the staff treating them.

Nimodipine and perfusion changes after stroke

BACKGROUND AND PURPOSE

Meta-analysis of previous trials of oral nimodipine in acute stroke has suggested a benefit when commenced within 12 hours of onset. We sought to study the effect of oral nimodipine on reperfusion after acute stroke and the relation between reperfusion and outcome.

METHODS

Fifty patients with acute middle cerebral artery territory cortical infarction were blindly randomized within 12 hours of onset to either oral nimodipine (30 mg every 6 hours) or placebo. Treatment was continued for 2 weeks. Cerebral blood flow was assessed with the use of 99mTc-hexamethylpropyleneamine oxime single-photon emission CT before therapy, 24 hours later, and at 3 months. Hypoperfusion was measured by a validated volumetric technique. Neurological impairment and functional outcome were assessed with the Canadian Neurological Scale and Barthel Index, respectively. Tissue loss was measured with CT at 3 months. Four patients were excluded from analysis for technical reasons.

RESULTS

Twenty-three patients received nimodipine, and 23 received placebo. In the nimodipine group, there was early reperfusion that was not maintained at outcome (P=0.01). In the placebo group, mean infarct hypoperfusion volumes showed no overall change. Nonnutritional reperfusion in nimodipine-treated patients was associated with adverse neurological (P=0.05) and functional outcome (P=0.06). There was, however, no difference in clinical outcome between the 2 groups.

CONCLUSIONS

Oral nimodipine administered within 12 hours enhanced acute reperfusion, but this was largely nonnutritional. Larger studies using a shorter treatment delay are required to evaluate the clinical efficacy of nimodipine in acute ischemic stroke.

Efficacy of high-dose glycine in the treatment of enduring negative symptoms of schizophrenia

BACKGROUND

Disturbances of N-methyl-D-aspartate (NMDA) receptor-mediated glutamatergic neurotransmission may play an important role in the pathophysiology of negative symptoms of schizophrenia. Glycine, a small nonessential amino acid, functions as an obligatory coagonist at NMDA receptors through its action at a strychnine-insensitive binding site on the NMDA receptor complex. Glycine-induced augmentation of NMDA receptor-mediated neurotransmission may thus offer a potentially safe and feasible approach for ameliorating persistent negative symptoms of schizophrenia.

METHODS

Twenty-two treatment-resistant schizophrenic patients participated in a double-blind, placebo-controlled, 6-week, crossover treatment trial with 0.8 g/kg per day of glycine added to their ongoing antipsychotic medication. Clinical assessments, including the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), the Simpson-Angus Scale for Extrapyramidal Symptoms, and the Abnormal Involuntary Movement Scale, were performed biweekly throughout the study. Clinical laboratory values and amino acid serum levels were monitored.

RESULTS

Glycine treatment was well tolerated and induced increased glycine (P=.001) and serine (P=.001) serum levels. Glycine administration resulted in (1) a significant (P<.001) 30%+/-16% reduction in negative symptoms, as measured by the PANSS, and (2) a significant (P<.001) 30%+/-18% improvement in the BPRS total scores. The improvement in negative symptoms was unrelated to alterations in extrapyramidal effects or symptoms of depression. Low pretreatment glycine serum levels significantly predicted (r= 0.80) clinical response.

CONCLUSION

These findings support hypoglutamatergic hypotheses of schizophrenia and suggest a novel approach for the pharmacotherapy of negative symptoms associated with this illness.

Spontaneous reperfusion after ischemic stroke is associated with improved outcome

BACKGROUND AND PURPOSE

The rationale behind thrombolytic therapy in acute ischemic stroke is penumbral salvage by rapid restoration of cerebral blood flow. The relationship, however, between early reperfusion (potentially composed of both nutritional and nonnutritional components) and outcome remains unclear.

METHODS

To establish the relationship between reperfusion parameters and outcome variables (Canadian Neurological Scale, Barthel Index, outcome CT scans), we used 99Tc-hexamethylpropyleneamine oxime (99Tc-HMPAO) single-photon emission CT (SPECT) to examine 41 acute ischemic stroke patients. All patients had at least 2 SPECT studies (24 with 3 studies), and none had been treated with thrombolytic or other acute investigational drugs.

RESULTS

A total of 106 studies were performed. Mean time to acute study was 9.2 hours; that for subacute study was 42 hours and for outcome study was 150 days. Hypoperfusion (HP) volumes at each of the 3 time points correlated with outcome clinical state and final infarct size. Both early reperfusion (61% of patients) and nutritional reperfusion alone (56%), which is early reperfusion maintained at outcome, were associated with improvement in clinical state and better functional outcome. Early HP volume change (acute minus subacute HP volume) and total HP volume change (acute minus outcome HP volume) also correlated with clinical improvement and better outcome.

CONCLUSIONS

This study establishes the benefit of spontaneous reperfusion after ischemic stroke and emphasizes the prognostic value of HP deficit volumes. 99Tc-HMPAO SPECT may be used to screen patients and group them according to perfusion deficit in acute stroke trials, thereby decreasing patient numbers required to show drug effect.

Congenital toxoplasma gondii infection diagnosed by PCR amplification of peripheral mononuclear blood cells from a child and mother

A case of congenital toxoplasmosis is presented, where diagnosis by PCR amplification of Toxoplasma gondii DNA from peripheral blood led to early treatment of the infant and seemingly normal brain development despite the presence of intracranial calcifications at birth. The mother, who experienced a subclinical infection during pregnancy, was PCR-positive for toxoplasma DNA in a sample of peripheral blood drawn after delivery.

Impact of selected medical conditions on self-reported lower-extremity function in Mexican-American elderly

OBJECTIVE

To examine the independent impact of common medical conditions on lower-extremity function in Mexican-American elderly.

DESIGN

Cross-sectional study using a probability sample of non-institutionalized Mexican Americans aged 65 or older.

SETTING

The five Southwestern states, Texas, New Mexico, Arizona, Colorado and California.

PARTICIPANTS

All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994.

MAIN OUTCOME MEASURES

Respondents were asked whether they could perform four activities related to lower-extremity function without help: walking across a small room, getting from a bed to a chair, walking up and down stairs, and walking half a mile. A summary measure of lower body disability created from these four items was regressed on seven common medical conditions plus five control variables using multiple logistic regression.

RESULTS

Adjusted Odds Ratios (OR) suggested that impaired lower-extremity function was associated with previous diagnosis of hip fracture (OR = 4.28), stroke (OR = 3.47), lower extremity arthritis (OR = 2.60), heart attack (OR = 2.29), diabetes (OR = 2.03) and obesity (OR = 1.50). Impaired lower-extremity function was significantly associated with older age (75+ years old), gender (female) and marital status (unmarried). In addition, there was a linear increase in the risk of function loss by number of medical conditions.

CONCLUSIONS

It appears that Mexican-American elderly diagnosed with medical conditions, especially stroke and hip fracture, have a high risk for lower-extremity dysfunction. These findings have implications for efforts to prevent or reduce lower-extremity dysfunction, as well as for the provision of community-based long-term care services for Mexican-American elderly.

Cytokine mRNA in Gaucher disease

Gaucher disease, the most common glycolipid storage disease, is caused by glucocerebrosidase deficiency, resulting in accumulation of glucocerebrosides within the macrophages of the reticuloendothelial system. The disease is characterized by great phenotypic heterogeneity, which can be explained only in part by the various mutations in the glucocerebrosidase gene, and by the amount of storage material in affected organs and tissues. Therefore, it has been postulated that some of the biochemical and clinical features may be related to the fact that "Gaucher" cells, as activated macrophages, express and release cytokines such as IL-1beta, IL-8, IL-6 and TNF-alpha which play a role in different physiological processes. In the present study, cytokine mRNA expression was measured in monocytes isolated from Gaucher patients and from healthy controls, using RT-PCR methodology with semiquantitative analysis. We found significantly increased expression of IL-1beta mRNA, as well as a trend to elevated TNF-alpha mRNA in Gaucher patients relative to healthy individuals. There were no statistically significant differences between Gaucher disease patients and controls with respect to two other tested cytokines (IL-6 and IL-8).

Volumetric analysis of cerebral hypoperfusion on SPECT: validation and reliability

A method of volumetric analysis of hypoperfusion on 99mTc-labeled hexamethylpropylene amine oxime SPECT has been developed. This analysis integrates both the size and severity of perfusion reduction, yielding an equivalent volume of cortical tissue having zero blood flow, or the effective hypoperfusion volume. This study aimed to validate the methodology in vitro using the Hoffman brain phantom and two different camera systems, to examine the relationship between spatial resolution and accuracy of volume measurement and to assess the interobserver variability in SPECT studies of stroke patients.

METHODS

Simulated cortical lesions of three different sizes were sequentially incorporated into the Hoffman brain phantom and imaged using both single- and triple-head camera systems. For each system and for each lesion size, successive acquisitions were performed using three progressively larger radii of camera rotation. The hypoperfusion volume for each study was measured three times by a blinded observer, and the percentage difference from the true lesion volume was then calculated. SPECT studies of 32 stroke patients were independently analyzed by two blinded observers.

RESULTS

At the smallest radii of rotation, mean (s.d.) percentage difference between observed and true volumes was 0.90% (4.80%) for the triple-head and 4.50% (11.58%) for the single-head system. The degree of overestimation was similar for both systems. Percentage overestimation was strongly associated with radius of rotation (B = 0.71 +/- 0.32, p = 0.04 for the triple-head system; B = 1.26 +/- 0.55, p = 0.03 for the single-head system) but not with lesion size. The mean difference between hypoperfusion volumes of stroke patients obtained by two observers was 0.045 (3.240) cm3, which was not significant.

CONCLUSION

This study has shown that this technique of volumetric analysis of regional hypoperfusion on SPECT is both highly accurate and reproducible between two different camera systems. The degree of overestimation chiefly relates to diminishing spatial resolution. Despite some element of subjectivity, the interobserver variability is negligible.

Nandrolone decanoate and intranasal calcitonin as therapy in established osteoporosis

This study used a randomized, 2 x 2 factorial design to evaluate over 2 years the effect of intranasal salmon calcitonin and intramuscular nandrolone decanoate on bone mass in elderly women with established osteoporosis. The study was double masked in relation to calcitonin and open in relation to nandrolone decanoate. One hundred and twenty-three women aged 60-88 years who had sustained a previous osteoporotic fracture, or had osteopenia, were recruited through an outpatient clinic. Women were assigned to one of four groups: (1) daily placebo nasal spray, (2) 400 IU intranasal calcitonin daily, (3) 20 intramuscular injections of 50 mg nandrolone decanoate (given as two courses of 10 injections) plus placebo nasal spray, or (4) 20 injections of 50 mg nandrolone decanoate plus 400 IU intranasal calcitonin daily. All subjects received 1000 mg calcium supplementation daily. Outcomes measured included changes in bone mineral density (BMD) at the lumbar spine, as measured by dual-energy quantitative computed tomography (DEQCT), in BMD of the proximal femur, and BMD and bone mineral content (BMC) of the lumbar spine and forearm, as measured by dual-energy X-ray absorptiometry (DXA). Significant positive changes from baseline in DXA BMC at the lumbar spine were observed over 2 years in the calcitonin group (5.0 +/- 1.9%, mean +/- SE) and in the nandrolone deconate group (4.7 +/- 1.9%) but not in the placebo group (1.1 +/- 2.2%) or the combined therapy group (0.7 +/- 1.8%). Modelling based on the 2 x 2 factorial design revealed that nandrolone decanoate was associated with a 3.8 +/- 1.8% (p < 0.05) gain in DXA BMD at the proximal femur. Modelling also revealed that calcitonin treatment was associated with a loss of 11.5 +/- 4.7% in DEQCT BMD at the lumbar spine and a loss of 3.7 +/- 1.8% in DXA BMD at the proximal femur (p < 0.05). There was in vivo antagonism between the two medications of 7.9 +/- 3.9% for DXA BMC at the lumbar spine. Both agents caused positive changes from baseline in lumbar spine BMC. Nandrolone decanoate had beneficial effects on BMD at the proximal femur. This dose of intranasal calcitonin was associated with deleterious effects on trabecular BMD at the lumbar spine and total BMD at the proximal femur. There may be significant clinical antagonism between these two medications.

The effect of medical conditions on the functional limitations of Mexican-American elderly

We examined the relationship of self-reported functional status to common medical conditions using a probability sample of 3050 noninstitutionalized Mexican-American men and women aged 65 or older and residing in the Southwestern United States (Arizona, California, Colorado, New Mexico, and Texas). All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. The questionnaire obtained information on self-reported functional status and prevalence of arthritis, cancer, diabetes, stroke, heart attack, and hip fracture. The prevalence of medical conditions ranged from 4.1% for hip fracture to 40.8% for arthritis. Prevalence of impairments in seven activities of daily living ranged from 5.4% for eating to 11.7% for bathing, while 25.1% could not walk up and down stairs, and 28.9% could not walk a half mile without help. In multiple logistic regression analyses, previous diagnoses of stroke and hip fracture were most predictive of functional limitations, though all conditions examined (arthritis, cancer, diabetes, stroke, heart attack, and hip fracture) were independently associated with increased odds of impairment in some activities of daily living. In general, the odds for functional impairment associated with specific medical conditions were higher than those previously published for non-Hispanic white populations. The fact that Mexican-American elderly who live in the community and who have medical conditions, especially stroke and hip fracture, are at high risk for functional impairment probably reflects the low rate of institutionalization in this population and has implications for the provision of community-based long-term care services for Mexican-American elderly.

Streptokinase increases luxury perfusion after stroke

BACKGROUND AND PURPOSE

Recent acute stroke trials have reported that intravenous streptokinase is associated with an increased risk of adverse outcomes. We aimed to study the effect of streptokinase on the nature of reperfusion and the relation between reperfusion and clinical outcome.

METHODS

We studied 24 patients in the Australian Streptokinase Trial with acute middle cerebral cortical infarction using 99mTc-hexamethylpropyleneamine oxime single-photon emission CT. Eleven of the 24 patients were scanned before therapy and again 24 hours later. The remaining 13 were scanned once either before therapy (1 patient) or after therapy (12 patients). All patients had outcome scans after 3 months. Infarct hypoperfusion was measured with a validated volumetric technique. Neurological impairment and functional outcome were assessed with the Canadian Neurological Scale and the Barthel Index, respectively.

RESULTS

Fifteen patients received streptokinase and 9 received placebo. There was no difference in early reperfusion between streptokinase and placebo. However, streptokinase was associated with a greater amount of nonnutritional reperfusion than was placebo (P = .04). This luxury perfusion was associated with poor functional outcome (P = .02).

CONCLUSIONS

This study suggests that streptokinase augments luxury perfusion after stroke. Luxury perfusion is associated with a worse outcome, which might be due in part to reperfusion injury.

Assessment of left ventricular function after radiofrequency and direct current atrioventricular node ablation

BACKGROUND

There is limited information available regarding the effect of catheter ablation of the antioventricular (AV) junction on left ventricular (LV) function. Both deterioration and improvement in LV function have been reported following direct current (DC) ablation of the AV junction. The deterioration of LV function following DC ablation of the AV junction may be due to the accompanying barotrauma, DC arcing and direct coagulation, or even the effects of chronic ventricular pacing. If this deterioration of LV function was a result of the accompanying effects of DC shock, the use of radiofrequency ablation (RF) should not result in deterioration of LV function.

AIM

To study LV function before and after different methods of AV junction ablation and in patients with chronic ventricular pacing without AV junction ablation.

MATERIAL

This study assessed LV function in patients following RF ablation, low energy DC ablation of the AV junction and compared the results with our previously reported finding in patients who had AV junction ablation using high energy DC shock. A group of patients undergoing permanent single chamber ventricular pacemaker implantation without AV junction ablation were selected as controls.

METHODS

All patients were paced in the ventricle at 110 beats/minute during LV function assessment by radionuclide angiography. Global LV function and segmental wall motion abnormalities were assessed before, immediately following and three months after ablation.

RESULTS

In the high energy DC ablation group, a fall in global LV function (50 +/- 3.0% to 43 +/- 3.0%, p = 0.02) and impairment of segmental wall motion were detected. Low energy DC ablation resulted in segmental wall motion impairment similar to high energy DC but without affecting global ejection fraction (47.0% +/- 6.7 to 45.5% +/- 3.1, p > 0.05). Neither RF ablation (44.0% +/- 3.3 to 45.3% +/- 3.5, p > 0.05), nor chronic pacing (46.7% +/- 4.9 to 47.0% +/- 2.9 p > 0.05) had any effect on global or segmental LV function.

CONCLUSIONS

Low energy DC or RF ablation of the AV junction does not affect global LV ejection fraction. The deterioration of global LV function after high energy DC shock ablation appears to be related to the accompanying effects of DC energy and not to the effects of chronic ventricular pacing.

A controlled trial of cisapride in anorexia nervosa

To determine the efficacy of cisapride, 10 mg three times daily, in improving gastric emptying, reducing distress during meals, and facilitating weight gain in anorexia nervosa, we conducted an 8-week, randomized, double-blind, placebo-controlled trial on 29 inpatients. Measures included scintigraphic gastric emptying studies at 0, 2, 4, and 8 weeks; subjective distress during meals measured by visual analogue scales; self-rating of degree of global improvement in symptoms associated with eating at end of study; and weight measured weekly. Gastric emptying improved significantly but equally in both groups over the study period. Yet subjective measures were better in the cisapride group; they rated themselves as more hungry (p = .02) and more improved on the global measure of change in symptoms (p = .02). Even so, the cisapride group did not gain more weight. The correlation between gastric emptying and weight gain was modest (r = .30; p = .11), and between gastric emptying and the subjective measures, virtually absent.

A prospective study of cortical scarring in acute febrile pyelonephritis in adults: clinical and bacteriological characteristics

Previous reports have demonstrated lesions on computerized axial tomography (CT), and nuclear scintigraphy (DMSA) in acute pyelonephritis (PN). We undertook a prospective study of all patients presenting to our hospital with PN over 40 months. Patients who fulfilled diagnostic criteria, were treated with intravenous antibiotics. Excluding two who were pregnant, all patients had imaging by intravenous urography (IVU), CT and DMSA during their admission. Urine samples were collected prior to treatment. Patients without IVU evidence of cortical scarring but with parenchymal defects on CT and/or DMSA underwent a repeat DMSA three or more months after the acute episode. Of the 164 patients, 142 were female. E. coli was found in 116 patients. Forty-six patients had an abnormality on IVU. Of the 106 patients without IVU evidence of cortical scarring, 59 had a defect on CT and/or DMSA. Late DMSA scans in 35 of these 59 patients showed a persistent abnormality in 77%. E. coli characteristics such as P-fimbriae and Type 1 fimbriae were not predictive of acute imaging abnormalities. Inhibition of E. coli growth by the addition of EDTA was highly predictive of acute CT and DMSA abnormalities with a sensitivity of 83.3% and a specificity of 82.8%. Acute pyelonephritis is often associated with acute CT and/or DMSA abnormalities which may evolve into renal cortical scars. Acute scan abnormalities can be predicted by the presence of E. coli which were susceptible to EDTA in culture. Late scarring could not be predicted by clinical features, response to treatment or antibiotic used.

Do Australian women have greater spinal bone density than North American women?

The interpretation of bone mineral densitometry results for a particular individual relies on valid reference data from a representative population sample. To establish local reference data, 411 Australian female volunteers had bone mineral densitometry performed at a single medical centre at the proximal femur and lumbar spine using a Hologic QDR 1000-W dual-energy X-ray absorptiometer. These data were compared with reference material from North American women compiled by Hologic. The Australian volunteers had, on average, 7% greater bone mineral density at the lumbar spine for the age range 25-55 years. Possible explanations for this include an actual population difference or the presence of a differential selection bias between the two samples.

Crossed cerebellar diaschisis and brain recovery after stroke

BACKGROUND AND PURPOSE

Although crossed cerebellar diaschisis is well recognized after stroke, there is controversy concerning its clinical correlations and serial changes, and little is known about its prognostic value.

METHODS

We studied crossed cerebellar diaschisis and cerebral hypoperfusion in 47 patients with acute middle cerebral cortical infarction using 99mTc-hexamethylpropyleneamine oxime and single-photon emission computed tomography within 72 hours of stroke onset. Thirty-one of these patients had outcome studies at 3 months; 15 of the 31 underwent an additional scan after acetazolamide injection. Tissue loss was determined with computed tomography, performed at outcome in 28 patients. Clinical stroke severity was assessed with the Canadian Neurological Scale and Barthel Index. Cerebellar blood flow asymmetry was studied in 22 healthy, age-matched control subjects.

RESULTS

Cerebellar blood flow asymmetry was significant in patients (mean +/- SE, 9.76 +/- 0.78%; P < .001) but not in control subjects (-0.22 +/- 0.56%). Crossed cerebellar diaschisis was strongly associated with infarct hypoperfusion volume at both acute (regression coefficient +/- SEb, b = 6.76 +/- 0.65; P < .001) and outcome stages (b = 6.13 +/- 0.63; P < .001). Cross-sectionally over the first 72 hours, infarct hypoperfusion volume decreased by 2% for each hour from onset (P < .05), while crossed cerebellar diaschisis remained unchanged. Canadian Neurological Scale score at the acute stage was negatively associated with acute crossed cerebellar diaschisis (b = -0.10 +/- 0.05; P < .05) after allowing for infarct hypoperfusion volume. Crossed cerebellar diaschisis did not change between acute-stage, outcome, and postacetazolamide scans. Acute-stage crossed cerebellar diaschisis predicted outcome Barthel Index score (b = -0.28 +/- 0.14; P = .05) and tissue loss (b = 3.81 +/- 0.96; P < .001) but was no longer an independent prognostic factor after allowing for acute-stage infarct hypoperfusion volume.

CONCLUSIONS

This study shows that crossed cerebellar diaschisis is a functional phenomenon that correlates with both stroke severity and infarct hypoperfusion volume and persists despite neurological recovery. Although acute-stage crossed cerebellar diaschisis has no prognostic value independent of acute-stage hypoperfusion volume, it might indicate the proportion of nutritional to nonnutritional perfusion at the infarct site and hence be useful in the evaluation of reperfusion therapies in the acute stage.

B cell-specific demethylation: a novel role for the intronic kappa chain enhancer sequence

We studied the molecular mechanism of demethylation and its role in kappa chain gene regulation. Following transfection into B cell cultures, this gene undergoes regional demethylation in a process that is developmentally regulated in a lineage- and stage-specific manner. Although a germline V kappa promoter is not required for the demodification activity, a fragment containing the intronic kappa chain transcriptional enhancer and the nearby matrix attachment region is essential. In its natural location downstream to the J kappa 5 sequence, this element induces bidirectional demodification of plasmid constructs in a distance- and orientation-independent manner. When this enhancer is placed in an upstream position, however, the kappa gene remains modified and transcriptionally inactive, demonstrating that demethylation is required for kappa chain activation. These studies suggest that the kappa enhancer plays a dual role in regulating B cell differentiation by inducing demethylation and by promoting tissue-specific transcription.

The Sickness Impact Profile for nursing homes (SIP-NH)

BACKGROUND

Valid, feasible measures of functional status are needed to evaluate the expanding nursing home population. This study attempts to increase relevance and reduce respondent burden of the Sickness Impact Profile (SIP) for nursing home residents while maintaining internal consistency and validity.

METHODS

231 residents from one academic and four community nursing homes, aged > or = 60 with a Mini-Mental State Exam score > or = 11, were study participants. Nominal group process was used to identify items and/or categories for removal. Candidate items were those that: represented restrictions of the nursing home environment, had weak item-total score correlations, and/or made minimal contribution to category internal consistency. Reduction was constrained by: minimum correlation of r = .90 between SIP and Sickness Impact Profile for Nursing Homes (SIP-NH) scores, coefficients alpha that fell within 95% confidence regions about predicted alpha. Convergent and discriminant validity were evaluated with the Katz Activities of Daily Living, Physical Disability Index, Geriatric Depression Scale, and Folstein Mini-Mental State Exam.

RESULTS

The SIP-NH contains 66 items, a 51.5% reduction. Correlations between the SIP-NH and SIP were: total score r = .98, Physical dimension r = .97, and Psychosocial dimension r = .97. Alpha coefficients all fell within the 95% confidence regions. The SIP and the SIP-NH did not differ in correlations with validating instruments.

CONCLUSIONS

The SIP-NH reduces respondent burden and has acceptable internal consistency and external validity. Potentially useful for discriminatory and predictive purposes, responsiveness to change will require longitudinal evaluation.

A comparative study of radionuclide venography and contrast venography in the diagnosis of deep venous thrombosis

BACKGROUND

The value of the radionuclide blood pool venogram in detecting deep venous thrombosis (DVT) has to date been inadequately evaluated. This is despite its lower complication rate than the gold standard of contrast X-ray venography.

AIMS

To compare the relative accuracy and inter observer variability of radionuclide blood pool and X-ray contrast venography as well as evaluate previous literature on radionuclide venography.

METHODS

Prospective comparison of radionuclide and contrast venography was performed in 39 patients. Sensitivity and specificity of radionuclide venography were compared to contrast venography and confidence intervals were measured using standard error calculations. A meta-analysis of previous studies was also performed.

RESULTS

Significant inter observer variation in reports was present in both radionuclide (37%) and contrast (22%) venograms. Using consensus reports sensitivity of radionuclide venography was 87% compared to contrast venography and specificity was 83%. These results are similar to those obtained in previous studies. Furthermore, sensitivity in specificity in the proximal veins were 90% and 92% respectively which were superior to sensitivity and specificity in the distal veins where it was 74% and 90% respectively.

CONCLUSION

The radionuclide venogram appears accurate in the proximal veins and in excluding but not diagnosing distal venous thrombosis.

Cerebral hypoperfusion in stroke prognosis and brain recovery

BACKGROUND AND PURPOSE

The value of acute cerebral blood flow measurements in stroke prognosis is controversial. No previous study has determined whether acute perfusion deficits independently add to a validated clinical prognostic score. We aimed to compare the value of acute hypoperfusion deficits with a quantitative clinical score in stroke prognosis and to correlate the changes in perfusion with brain recovery.

METHODS

Volumetric analysis of regional hypoperfusion was performed in 38 patients with middle cerebral infarction within 72 hours of onset by use of single photon emission computed tomography and 99mTc hexamethylpropylene amine oxime. Stroke severity was assessed by the Canadian Neurological Score and Barthel Index. Allen's prognostic score was determined acutely in all patients. Clinical outcome was evaluated in 36 of 38 patients, of whom 18 had repeat blood flow studies.

RESULTS

Acute hypoperfusion correlated with both the outcome Barthel Index (P < .001, r = -.61) and Canadian Neurological Score (P < .001, r = -.64). Allen's score correlated better with both the outcome Barthel Index (P < .001, r = .80) and Canadian Neurological Score (P < .001, r = .81). Acute hypoperfusion deficits, after allowing for Allen's score, independently predicted neurological but not functional outcome. Despite overall neurological improvement, mean hypoperfusion increased on the repeat blood flow studies (P < .05).

CONCLUSIONS

Volumetric analysis of acute regional hypoperfusion within 72 hours of onset predicts stroke outcome after 3 months, but Allen's score is a better prognostic method. Neurological recovery is not associated with chronic infarct reperfusion.

Forearm arterial vascular responsiveness in insulin-dependent diabetic subjects

The vascular reactivity of forearm arterioles was measured in 16 control subjects (C) and 30 insulin-dependent diabetic (IDDM) subjects, 16 of whom were shown to have microvascular and/or neuropathic complications (DC) including 8 with autonomic neuropathy (DCa) and 14 were shown to be free of complications (DNC). Forearm blood flow was measured by strain gauge plethysmography basally, following a cold pressor stress and following a period of arterial occlusion (reactive hyperaemia). The tests were repeated 24 h later following aspirin treatment. Both C and DNC showed a significant reduction in blood flow in the cold pressor test (C 0.64 +/- 0.12, DNC 0.89 +/- 0.22 ml/100 ml forearm tissue/min reduction in flow P < 0.005), while DC showed no significant response. Reactive hyperaemia was significantly greater in C than in DNC or DC (8.37 +/- 1.14, 5.51 +/- 1.27 and 4.95 +/- 0.75 ml/100 ml tissue/min, respectively, P < 0.02). In the DC group, DCa had significantly less response than those without autonomic neuropathy. Aspirin treatment restored the response of DNC but not DC to normal, suggesting that the abnormality in the former group may have been due to overproduction of a vasoconstrictive cyclooxygenase product (such as thromboxane A2). It is concluded that the abnormalities of vasomotor responses in diabetic subjects are complex and are apparently dependent on autonomic neuropathy, humoral and perhaps structural changes.

The effect of aging on intact PTH and bone density in women

OBJECTIVE

To determine whether age-related bone loss is negatively associated with serum intact parathyroid hormone (PTH).

DESIGN

Survey.

SETTING

University hospital outpatient department.

PARTICIPANTS

100 community-dwelling women, age 18 to 80, recruited as a convenience sample.

MEASUREMENTS

Dependent variables--bone density at the spine and femoral neck by dual-energy X-ray absorptiometry. Independent variables--age, menopausal status (binary) and intact serum PTH by Allegro immunometric assay.

RESULTS

Post-menopausal women had higher serum PTH and lower bone density of spine and femoral neck than premenopausal women. Bone density at the spine decreased with age, but this effect was accounted for by menopausal state. Bone density at the femoral neck decreased with age even after adjusting for menopause. Log PTH was negatively associated with bone density at the femoral neck but not significantly at the spine. Multiple regression analysis adjusting for age and menopause showed no significant association between intact PTH and bone density at the spine or the femoral neck.

CONCLUSION

Although this study confirmed the rise in intact PTH with age, there is no evidence that this is the mediator of age-related bone loss.

99Tcm-labelled IgG scanning does not predict the distribution of intestinal inflammation in patients with inflammatory bowel disease

In order to assess the value of 99Tcm-labelled-immunoglobulin G(99Tcm-IgG) in the assessment of the activity and distribution of intestinal inflammation in patients with inflammatory bowel disease (IBD), 99Tcm-IgG scans were performed in 18 patients. Patients were divided clinically into two groups, those with (ten patients) and those without (eight patients), intestinal inflammation. Disease activity and distribution were assessed by 111In-oxine granulocyte scanning and/or histological extent of inflammation at endoscopy or surgery in all patients with IBD and most of those without intestinal inflammation. In the assessment of the presence or absence of inflammation, a sensitivity of 80% and specificity of 87% were achieved. However, when the localization of intestinal inflammation was evaluated, only five of eight true positive scans were concordant with the distribution of intestinal inflammation as determined by other methods. Thus, significant areas of inflammation were missed in five of ten patients with IBD (two false negative, three incorrect localization of inflammation). Although 99Tcm-IgG scanning appears to have moderate sensitivity and acceptable specificity in the detection of intestinal inflammation, it performs poorly in assessing the distribution of inflammation and is, therefore, of little value in the assessment of patients with suspected or proven IBD.

Correlations between cerebral arterial velocities, blood flow, and delayed ischemia after subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Elevated middle cerebral erythrocyte velocities and tissue hypoperfusion have been correlated with delayed ischemia after subarachnoid hemorrhage, but few studies have compared serial arterial velocities with cerebral blood flow and neurological deficits.

METHODS

Serial measurements of middle cerebral velocities, using transcranial Doppler ultrasonography, were performed in 34 patients after subarachnoid hemorrhage and correlated with cerebral blood flow, measured in 20 of the 34 using single-photon emission computed tomography with technetium-99m hexamethylpropylene amine oxime and neurological evidence of delayed ischemia.

RESULTS

In 16 patients without delayed ischemia, eight had evidence of vasospasm (greater than 120 cm/sec), but only one of seven had hypoperfusion, suggesting that vasospasm might be more common than hypoperfusion in this group (p = 0.1). In 10 patients with delayed ischemia and a lateralizing deficit, both asymmetrical middle cerebral vasospasm (eight of nine with vasospasm) and hypoperfusion (six of six studied) were concordant with the clinically ischemic hemisphere (p less than 0.05). Vasospasm occurred with nonlateralized delayed ischemia in seven of eight patients and with hypoperfusion in five of six, affecting the anterior cerebral territory in three.

CONCLUSIONS

Concordant vasospasm and hypoperfusion were most often present in patients with delayed ischemia and lateralizing neurological deficits. Discordant results reflect inherent limitations and the different levels of the circulation monitored by the two techniques.

Value of positive technetium-99m leucocyte scans in predicting intestinal inflammation

The value of positive scans of autologous 99mTc-labelled leucocytes in the detection of intestinal inflammation was assessed in 29 patients with known inflammatory bowel disease and a high probability of intestinal inflammation and 58 with a low probability of intestinal inflammation comprising 37 with intestinal symptoms and 21 with suspected abscess. Autologous leucocytes were labelled with 99mTc using either of the established methods. In patients with inflammatory bowel disease, 3/13 with ileocaecal and 1/11 with colonic accumulation of 99mTc were incorrectly diagnosed in that there was no histological evidence of inflammation in those regions. In the low probability patients, all 26 positive images were false positives: there were 19 in the ileocaecal and 7 in colonic regions and no differences between the two subgroups. False positives were more common in low probability than high probability patients (p = 0.011). The results were independent of the 99mTc cell labelling technique used. Three false positive patients also had normal scans for 111In-labelled granulocytes. The time of first detection of 99mTc in the bowel was earlier in true than in false positive patients (92% v 33% within 1 h, p = 0.008), the false positive rates in the first hour of imaging being 5% in high and 15% in low probability patients. In 99mTc scintigraphy, the appearance of the isotope in the intestine occurs commonly in the absence of inflammation irrespective of the cell labelling technique used. In high probability patients, imaging at 1 h can more reliably discriminate true from false positives and retain clinical usefulness. In low probability patients specificity remains unacceptable and 99mTc-labelled leucocyte scanning in these patients is of little value as a positive predictor of intestinal inflammation.

Ventricular dysfunction following direct-current shock atrioventricular junction ablation

Catheter-induced His bundle ablation for refractory supraventricular arrhythmias is most commonly performed with direct-current shock energy of 200-300 joules. The high energy pulse delivered by direct-current shock produces a lesion in the atrioventricular node by fulguration, with the residual energy being dissipated as a pressure wave. The effect of direct-current shock His bundle ablation on global and regional ventricular function was assessed in 14 consecutive patients by radionuclide ventriculography performed before and after ablation and again three months later. All studies were performed with ventricular pacing at 110 bpm. Global left ventricular ejection fraction was found to be significantly reduced at the three month study (0.43 +/- 0.03 vs 0.50 +/- 0.03, pre ablation, p = 0.02). A significant reduction in wall-motion score was also seen in six of the seven patients who had normal wall motion in pacing rhythm prior to ablation. Deterioration was mainly seen at the left and right ventricular apices. The observed reduction in ventricular function that follows direct-current shock His bundle ablation may result from myocardial damage from electro-coagulation or from barotrauma and supports continued investigation into alternative, less traumatic energy sources for the procedure.