The Perception of Art among Patients and Staff on a Renal Dialysis Unit

This study investigated the purpose and effectiveness of giving outpatients an opportunity to engage in art activities while receiving dialysis treatment. A mixed method study was conducted. 21 semi-structured interviews were conducted with outpatients attending the dialysis unit and 13 surveys of clinicians were completed. The principle reasons to partake in the art activity programme included: to pass time, to relieve boredom, to be creative, to try something new, distraction from concerns, to stay positive and to achieve something new. Patients who did not participate in the programme pass their time primarily by watching TV or sleeping. All staff who partook in the survey were satisfied with the programme and wanted it to continue. Our findings indicate that the creative arts programme is viewed positively by staff and patients alike, and might be useful in other hospital departments. Further in depth qualitative research would be useful to interrogate the potential effect of engagement in art on positive mental health and quality of life for patients with chronic conditions.

Current management of corticosteroid-induced osteoporosis: variations in awareness and management

BACKGROUND

Guidelines for the prevention of corticosteroid-induced osteoporosis (CIO) have been widely published. There are no guidelines on the use of gastro-protectants with corticosteroids (CS).

AIMS

To determine whether patients receiving CS therapy are evaluated and treated for osteoporosis risk, how management varied by steroid dose and diagnosis, and how many patients received gastro-protection.

METHODS

A retrospective audit of 4,350 patients presenting to four medical specialities.

RESULTS

One hundred and fifty-one patients prescribed CS were identified. Indications for CS therapy included renal transplantation (32%) and asthma/respiratory diseases (23%), inflammatory arthritis/vasculitis (32%) and inflammatory bowel disease/auto-immune hepatitis/other (13%). Risk of osteoporosis was mentioned in 13% of charts. The prescription rates for bone protection agents varied from 69% to 4% according to the medical speciality attended. Gastro-protectants were prescribed for 44% of patients.

CONCLUSION

There are large variations among medical specialties both in the prescription of gastro-protectant agents and in the use of measures to prevent CIO. Simpler guidelines could facilitate rational prescribing in these patients.

Skew deviation and inferior oblique palsy

PURPOSE

To describe ocular motility and neuro-ophthalmologic findings in six patients with an ocular tilt reaction (OTR) that mimicked an inferior oblique palsy (IOP).

DESIGN

Observational Case Series.

METHODS

Series of six patients presenting to tertiary care pediatric or neuro-ophthalmologist.

RESULTS

Five patients had ocular motility and three-step test results suggesting an IOP; one patient had a suspected bilateral IOP. All six patients had excyclotorsion of the hypotropic eye, and four had incyclotorsion of the hypertropic eye. This is contrary to that expected with an IOP (incyclotorsion of the hypotropic eye). In addition, all six patients had other neurologic findings in the history or examination that were associated with neurologic insult rather than an isolated IOP. Two patients had surgery consisting of a superior rectus recession; this was successful in eliminating diplopia in both patients and in eliminating the vertical deviation and head posturing in one patient.

CONCLUSION

While many vertical deviations that appear to be due to an inferior oblique palsy based on the results of the three-step test may be caused by inferior oblique weakness, skew deviation should also be considered in any patient with a history of head trauma, or other neurologic findings. The cyclotorsion observed in IOP is opposite that seen with OTR, and differentiates the two entities clinically. We postulate that these deviations are caused by damage to the otolithic projections that correspond to those from the ipsilateral posterior semicircular canal (on the side of the hypotropic eye).

Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids

A patient with chronic daily headaches developed overt signs of Cushing syndrome during treatment with serial occipital nerve block injections. Investigation demonstrated an exogenous source of corticosteroids as the cause of the Cushing syndrome in this patient, thus, implicating the corticosteroid component of the occipital nerve blocks. To our knowledge, this is the first report of Cushing syndrome caused by occipital nerve blockade. Caution is warranted in employing even usual therapeutic doses of synthetic corticosteroids, particularly in long-acting or depot preparations.

Visual field defects after temporal lobe resection: a prospective quantitative analysis

OBJECTIVE

To evaluate and quantify prospectively visual field changes in patients undergoing temporal lobe resections for intractable epilepsy.

BACKGROUND

Visual field abnormalities occur after temporal lobe resections for epilepsy; however, we have not encountered published reports using automated static visual field analysis.

METHODS

Humphrey visual fields (program 30-2) were obtained before and after partial temporal lobe resection in 32 consecutive patients with intractable epilepsy. A quantitative point-by-point analysis was made in the affected superior quadrant, and the defects were averaged for the whole patient group.

RESULTS

Thirty-one patients developed a visual field defect, but none was aware of the defect. The points nearest fixation were relatively spared. The defects were greatest in the sector closest to the vertical meridian in the eye ipsilateral to the resection. The ipsilateral and contralateral mean field defects also differed in both topography and depth. A significant correlation was found between the extent of lateral temporal lobe resection and the degree of the defect in the contralateral eye.

CONCLUSIONS

There are differences in the shape and depth of the ipsilateral and the contralateral field defects not previously reported. These findings demonstrate that certain fibers from the ipsilateral eye travel more anteriorly and laterally in Meyer's loop, and support the hypothesis that visual field defects due to anterior retrogeniculate lesions are relatively incongruous because of anatomic differences in the afferent pathways. Automated perimetry is a sensitive method of evaluating and quantifying visual field defects.

Comparison of 24-2 and 30-2 perimetry in glaucomatous and nonglaucomatous optic neuropathies

OBJECTIVE

To determine whether the 24-2 Humphrey visual field (HVF) (Humphrey, San Leandro, CA) strategy provides information comparable to that provided by the 30-2 strategy in patients with optic nerve disease.

METHODS

In part A of the study, an occluder device was designed to cover the additional outer 22 points tested in the 30-2 strategy of 187 HVFs from neuro-ophthalmology patients with nonglaucomatous optic neuropathy and 206 HVFs from patients with glaucoma. This device converted the gray scale and probability plots of the 30-2 HVF to a 24-2 field. Fields were initially read using the occluder and then were read in a masked manner without the occluder and compared. In part B, 15 healthy volunteers performed both 30-2 and 24-2 HVFs. Testing time and global indices were compared. Ninety-five percent of the fields in the neuro-ophthalmology patients, 96% of the fields in patients under observation for suspected glaucoma, 98% of the fields in patients with ocular hypertension, and 100% of the fields in patients with glaucoma were read similarly with the 24-2 and 30-2 strategies. In the few cases in which a discrepancy was noted between the 24-2 and the 30-2 fields, appropriate clinical management would not have been compromised by using the 24-2 strategy. Most of these cases were in patients with idiopathic intracranial hypertension and very subtle nerve fiber bundle defects. The 24-2 strategy had a significantly lower pattern standard deviation (P < 0.01) and corrected pattern standard deviation (P = 0.05) than did the 30-2 strategy. In addition, the 24-2 strategy shortened the standard threshold testing time by 28% in normal volunteers (P < 0.0001 ).

CONCLUSIONS

In most cases, the 24-2 testing strategy provides information comparable to that provided by the 30-2 strategy in a shorter time and with less variability. A 30-2 HVF may be warranted in patients under observation for evolving idiopathic intracranial hypertension.

Tonic ocular tilt reaction simulating a superior oblique palsy: diagnostic confusion with the 3-step test

BACKGROUND

The tonic ocular tilt reaction (OTR) consists of vertical divergence of the eyes (skew deviation), bilateral conjugate ocular torsion, and paradoxical head tilt. The head and superior pole of both eyes are rotated toward the hypotropic eye.

OBJECTIVE

To describe ocular motility and torsion findings in 5 patients with OTRs that mimicked superior oblique palsies (SOPs).

RESULTS

In 5 patients, results of the 3-step test suggested an SOP (bilateral in 1 patient); however, no patient had the expected excyclotorsion of the hypertropic eye. Two patients had conjugate ocular torsion (intorsion of the hypertropic eye and extorsion of the hypotropic eye), and 2 patients had only intorsion of the hypertropic eye. All had other neurologic features consistent with more widespread brainstem disease.

CONCLUSIONS

Vertical ocular deviations that 3-step to an SOP are not always caused by fourth nerve weakness. When a patient with an apparent fourth nerve palsy has ocular torsion that is inconsistent with an SOP, OTR should be suspected, especially if vestibular system or posterior fossa dysfunction coexists. The rules for the 3-step test for an SOP may be fulfilled by damaging the otolithic projections corresponding to projections of the contralateral anterior semicircular canal. Because results of the Bielschowsky head tilt test may be positive in patients with the OTR, the feature distinguishing OTR from an SOP is the direction of torsion. We advocate use of a fourth step-evaluation of ocular torsion-in addition to the standard 3 steps.

Stereotactic ventriculoperitoneal shunt for idiopathic intracranial hypertension: technical note

OBJECTIVE

Lumboperitoneal shunting is the bastion of neurosurgical management for idiopathic intracranial hypertension (IIH). However, recent studies document a high failure rate for this procedure. The present study was designed to explore the feasibility of placing ventriculoperitoneal shunts under stereotactic control into patients with IIH as an alternative to lumboperitoneal shunting.

METHODS

Seven patients with IIH for whom medical management had failed underwent stereotactic implantation of ventriculoperitoneal shunts.

RESULTS

Shunt placement was successful and uncomplicated in each case. Five of seven patients experienced complete resolution of papilledema. The remaining two patients showed resolving papilledema. Six of seven patients experienced resolution of headache. The remaining patient continued to have headaches despite a radionuclide study demonstrating normal shunt function.

CONCLUSION

Our results suggest that stereotactic ventriculoperitoneal shunting may be a reasonable alternative to lumboperitoneal shunting in those patients with IIH who require surgical intervention.

Unusual ocular motility disturbances with increased intracranial pressure

We evaluated nine patients with external ophthalmoparesis and increased intracranial pressure. The eye movements normalized when the intracranial pressure was controlled. Investigations for an underlying cause of elevated cerebrospinal fluid pressure are warranted when ocular motility disorders are present.

False-negative hydroxyamphetamine (Paredrine) test in acute Horner's syndrome

PURPOSE

To describe a false-negative hydroxyamphetamine test.

METHOD

Two patients with acute unilateral Horner's syndrome whose pupils initially dilated equally to hydroxyamphetamine had pharmacologic localization to the postganglionic nerve in the second week following the onset of symptoms.

RESULTS

Neuroimaging confirmed the postganglionic location in both cases.

CONCLUSION

Falsely negative localization with hydroxyamphetamine can occur during the first week after injury, during which time the function of the boutons at the presynaptic terminal is lost.

Oculopalatal myoclonus after the one-and-a-half syndrome with facial nerve palsy

PURPOSE

The one-and-a-half syndrome is an eye movement disorder characterized by a unilateral gaze palsy and an ipsilateral internuclear ophthalmoplegia. The authors describe a previously unrecognized association between the one-and-a-half syndrome and oculopalatal myoclonus (OPM).

METHODS

Five clinical cases are presented, with pertinent physical findings and radiologic studies.

RESULTS

A previously unrecognized association of the one-and-a-half syndrome with subsequent development of OPM appears to exist. Involvement of the facial nerve in patients with the one-and-a-half syndrome may be a predictor of the subsequent development of OPM.

CONCLUSION

Patients with the one-and-a-half syndrome and facial nerve palsy should be followed closely for possible future development of OPM.

False-negative cerebral radionuclide flow study, in brain death, caused by a ventricular drain

A radionuclide cerebral blood flow study demonstrated normal flow in the face of clinical and electrical brain death in a patient who had a ventricular drain. After the drain became obstructed and was removed, a further radionuclide study demonstrated no flow, confirming the role of the drain in the earlier false-negative studies.

Spontaneous visual recovery from traumatic optic neuropathy after blunt head injury

Four patients who developed immediate blindness (no light perception) after indirect traumatic optic neuropathy caused by blunt head injury recovered vision without surgical intervention. In one patient, whose affected eye recovered to a visual acuity of 20/50 + 2, corticosteroids were not used. In two of the other patients, visual recovery began before corticosteroids were instituted. One patient recovered a visual acuity of R.E.: 20/15, one recovered a visual acuity of L.E.: 20/25-2, and one recovered a visual acuity of R.E.: 20/200 but with useful temporal field vision. Many investigators advocate aggressive surgical therapy for indirect neuropathy, particularly when corticosteroids fail. Significant recovery may occur despite no light perception, however, with medical therapy or even without therapy.

Combined gaze palsy of horizontal saccades and pursuit contralateral to a midbrain haemorrhage

A midbrain haemorrhage, revealed by CT, caused a contralateral supranuclear horizontal gaze palsy of both saccades and foveal pursuit. These findings confirm the hypothesis that the supranuclear pathways for pursuit decussate to the contralateral midbrain and then decussate back before innervating the ipsilateral paramedian pontine reticular formation.

Chiasmal apoplexy: Hemorrhage from a cryptic vascular malformation in the optic chiasm

We describe three patients with acute chiasmal visual field loss caused by hemorrhage within an intrachiasmal arteriovenous malformation. One patient had five episodes; vision improved three times without treatment and twice after surgical decompression. Surgical intervention restored vision in two of the three patients. The role for surgery is indefinite, but may be indicated if the visual defect remains static for 1 week or progresses. Decompression is likely to be most effective if done early. The approach to the optic chiasm should be transcranial, not transsphenoidal. A radiologically normal sella turcica favors the diagnosis of chiasmal apoplexy in the acute chiasmal syndrome.

Painful Extremities and Neurological Disorder in Essential Thrombocythaemia

Six of 20 patients with essential thrombocythaemia had neurological features and 8 had peripheral vascular symptoms. Four had cerebrovascular ischaemia or stroke and 3 had gangrene. Pain in the extremities may be a striking symptom in this disorder.

Wernicke's encephalopathy: a predictable complication of hyperemesis gravidarum

Wernicke's encephalopathy occurred during prolonged intravenous feeding in two patients with hyperemesis gravidarum. Delay in diagnosis caused a protracted illness and persisting neurologic deficits in both patients. Because of its association with chronic alcoholism, the possibility of Wernicke's encephalopathy may not be considered early enough, if at all, in other situations; it is too frequently not discovered until postmortem examination. The disease may complicate other neurologic disorders due to nutritional deficiency, but can be prevented by the timely administration of parenteral thiamine.

Downbeat nystagmus with a pseudocycloid waveform: improvement with base-out prisms

Downbeat nystagmus in primary position and oscillopsia resulted from nutritional deficiency during prolonged intravenous therapy of a patient with hyperemesis gravidarum. Wide bandwidth infrared oculography demonstrated a pseudocycloid nystagmus waveform with an increasing-velocity exponential slow phase. Because the oscillopsia decreased and the nystagmus was damped with convergence, visual acuity improved with the addition of base-out prisms to each spectacle lens.

Silicon as a potential uremic neurotoxin: trace element analysis in patients with renal failure

We analyzed multiple trace elements in tap water, dialysis fluids, and CSF of patients on dialysis and with chronic renal insufficiency. Before placement of a deionizer in the dialysis unit, we found elevated levels of aluminum, barium, copper, silicon, and zinc in tap water and dialysis fluids. These were corrected by the deionizer. CSF silicon content was increased in patients with chronic renal insufficiency and on dialysis; CSF aluminum, barium, copper, and zinc were normal.

Studies of hypothalamic function in Huntington's chorea

In eight patients with classical Huntington's chorea hypothalamic function was assessed by the insulin tolerance test, the thyrotrophin releasing hormone test, the gonadotrophin releasing hormone test and water deprivation and the results compared with those of 10 control subjects. All patients ceased to have choreiform movements for approximately 60 minutes during the insulin tolerance test. Four of the patients failed to show clinical features of stress in response to hypoglycaemia. The fasting blood glucose level and blood glucose response to insulin were similar for the two groups. However, the response of plasma cortisol (p less than 0.05) and of growth hormone (p less than 0.05) to hypoglycaemia was earlier in patients than controls, though peak responses were the same for each group. The thyrotrophin releasing hormone test revealed no difference in basal levels of thyroid stimulating hormone in either group, or in peak response to thyrotrophin releasing hormone or in the increment at 20 minutes. One of the patients had a delayed response typical of a hypothalamic disorder, whereas none of the controls had such a response. Mean free thyroxine index levels for each group were similar. There was no difference in basal prolactin level, or in the increment or in the peak level in response to thyrotrophin releasing hormone between each group as a whole or when the males and females were analysed separately. Because of small subgroups, the data from the gonadotrophin releasing hormone test were difficult to analyse, but no clear differences or obvious abnormalities emerged. Water deprivation revealed no evidence of inability to concentrate urine in either group and hence no indication of impaired antidiuretic hormone function. The study supports previous findings of altered hypothalamic function in patients with Huntington's chorea but further suggests that serotoninergic rather than dopaminergic mechanisms may be altered.

Intracranial venous thrombosis in the first trimester of pregnancy

We describe a fatal case of intracranial venous thrombosis occurring in early pregnancy. Such thrombosis usually occurs in late pregnancy or the puerperium but rarely during the first trimester of pregnancy. Computerized axial tomography suggested massive cerebral venous infarction. Necropsy findings showed not only cerebral venous thrombosis but also extensive pelvic and iliac vein thromboses. The relationship of cerebral venous thrombosis and pregnancy is discussed and the literature reviewed.