Prothrombotic and antithrombotic factors are elevated in patients with type 1 diabetes complicated by microalbuminuria

Increased urinary albumin loss in patients with Type 1 diabetes is associated with accelerated atherosclerosis. Prothrombotic factors known to be associated with cerebrovascular and coronary artery disease in the general population, antithrombotic factors, were studied in 52 patients with Type 1 diabetes and varying urinary albumin loss and 24 non-diabetic control subjects. Fibrinogen increased from 2.5 g l-1 (95% confidence interval 2.3-2.8) in control subjects and 2.8 g l-1 (2.6-3.0) in diabetic patients without microalbuminuria to 3.1 g l-1 (2.7-3.5) with microalbuminuria (p < 0.005 vs control; p < 0.001 vs without microalbuminuria). Factor VIIc increased from 81% (75-86% in non-diabetic control subjects and 84% (78-90%) in diabetic patients without microalbuminuria to 103% (89-117%) with microalbuminuria (p < 0.005 vs control; p < 0.05 vs without microalbuminuria) and 118% (86-150%) with albuminuria (p < 0.005 vs control and p < 0.001 vs without microalbuminuria). Levels of the antithrombotic factors protein C, protein S, and antithrombin III also rose in the diabetic patients with evidence of renal damage. Elevation of prothrombotic factors has been associated with increased risk of microvascular disease, whereas elevation of antithrombotic factors has no known protective effect. Therefore, this pattern of alteration of haemostatic factors in diabetic renal disease may contribute to the increased risk of vascular disease associated with both microalbuminuria and albuminuria.

Absence of REM sleep, altered NREM sleep and supranuclear horizontal gaze palsy caused by a lesion of the pontine tegmentum

A 27-year-old woman with a mass lesion confined to the pontine tegmentum had absence of rapid eye movement (REM) sleep and abnormal nonrapid eye movement (NREM) sleep with no sleep spindles when the sole neurologic manifestation was a bilateral supranuclear horizontal gaze palsy. This study suggests that the tegmentum nuclei associated with REM sleep generation in humans and the pathways that control horizontal eye movements are closely related. Furthermore, these findings indicate that bilateral damage of the pontine tegmentum is necessary for REM sleep abolition. Interruption of connections between the tegmentum of the pons and the reticular nuclei of the thalamus could be the cause of the absence of sleep spindles.

A busy urban geriatric day hospital: analysis of one year's activity

Lightburn Geriatric Day Hospital is a 30-place unit sited adjacent to Geriatric Assessment and Rehabilitation wards and three miles from the local district general hospital in east Glasgow. The service serves an urban population of 25,000 persons aged 65 or more. During 1991 a data capture form was used to prospectively record Day Hospital referral patterns and activity. There were 731 new patient referrals, accounting for a total of 5,780 patient attendances. Thirty-eight per cent of new patients attended without prior screening (unscreened General Practitioner (GP) referrals). Booked occupancy was 85.5%, actual occupancy 76%. The average period of attendance was three weeks (median number of attendances: 7) and 18% of attenders required in-patient care. Specific after-care arrangements were made for 85% of patients on discharge from day hospital. Low rates for re-attendance (within three months of day hospital discharge) and chronic attendance (more than three months) as well as favourable responses from surveys of both GPs and patients suggest effective use of the Day Hospital resource, but more direct measures of Day Hospital effectiveness are required.

Recurrent hypersomnia in two adolescent males with Asperger's syndrome

Two individuals with Asperger's syndrome, a rare pervasive developmental disorder, developed recurrent episodes of hypersomnia and abnormal behavior (Kleine-Levin syndrome) during adolescence. The possible etiological role of developmental structural brain anomalies and the differential diagnosis of recurrent hypersomnia and abnormal behavior in patients with pervasive developmental disorders are discussed.

Visitors' perceptions of continuing care

One hundred and sixty-one replies (72% response rate) to a questionnaire sent to regular visitors of elderly continuing care patients showed that 73% of the visitors were first degree relatives. Sixty three per cent visited more than once per week, and were more likely to do so when the distance travelled was less than five miles (p less than 0.01) and the cost under pounds 2.00 (p less than 0.01). The physical surroundings and nursing care were rated as adequate or better by 80% and 92% respectively. Numbers of nurses were rated as inadequate by 44% and numbers of physiotherapists as inadequate by 46%. Increasing the numbers of nurses was suggested as the measure that would most improve the patients' quality of life. To facilitate visiting, continuing care units should be sited close to the community they serve.

Cervical magnetic stimulation

We stimulated the cervical region with a 9-cm-diameter magnetic coil on centered on the spinous processes in 21 normal subjects. We obtained maximal amplitudes with clockwise coil current in right-sided upper extremity muscles and counterclockwise coil current in left-sided upper extremity muscles. Optimal stimulation sites for biceps, triceps, and abductor digiti minimi were C-3 or C-4, C-4 or C-5, and C-4, C-5, or C-6, respectively. The latencies of the muscle responses varied little in the same subject in spite of marked amplitude changes due to suboptimal position of the coil or submaximal stimulator output. In abductor digiti minimi, the amplitude of the muscle response on cervical magnetic stimulation was 9 to 100% of the supramaximal amplitude on wrist electrical stimulation. We established normal values for latency, amplitude, and interside differences for the above 3 upper extremity muscles. The findings were reproducible, and the latencies obtained with large coils from different manufacturers in the same subjects were comparable. We found no advantage in bipolar recording over tendon-belly montage. Comparison of magnetic and electrical needle root stimulation in the same subjects showed that the magnetic stimulus was more proximal in biceps and triceps, and that the site of excitation was approximately the same in abductor digiti minimi. Indirect assessment of the longitudinal site of excitation based on F-wave minimal latency indicated that excitation occurred within millimeters of the emergence of axon of the peripheral motor neuron.

Magnetic stimulation of the human motor cortex: facilitation and its relationship to a visual motor task

Transcranial magnetic stimulation of the motor cortex can evoke motor responses in small hand muscles. This response can be facilitated by a background muscle contraction of the target muscle, resulting in an enhanced compound muscle action potential (CMAP) with a shorter onset latency. A number of intracortical mechanisms may account for this facilitatory effect, including, in part, direct input from visual to motor cortex. We studied the facilitation produced by a visual-motor task and compared those results with the facilitation produced by the same task without the visual cues. No differences in facilitation of amplitude or latency were observed. This suggests that there is no direct influence exerted by the visual cortex upon those elements of the motor cortex activated by a tangential magnetic stimulus, i.e., corticocortical and corticospinal neurons and their processes. Also, the large majority of facilitation (90%) was produced by a very small background voluntary contraction (less than 5% of maximum), indicating that any mild-to-moderate contraction of the target muscles will produce a consistent response for clinical measurements.

Are HLA class II genes controlling susceptibility and resistance to Brazilian pemphigus foliaceus (fogo selvagem)?

In order to investigate the possible association between Brazilian pemphigus foliaceus and HLA, we studied 48 patients and 74 matched controls, all Brazilian Caucasoids, for HLA-A,B,C; DR1 to DRw8 and DQw1 to DQw3. The frequencies of DR1, DR4 and B16 were significantly increased, while DR7 was significantly decreased among the patients. Furthermore DQw2, likewise the DR specificities associated with it - DR3 and DR7 - never occurred among the patients in the absence of the susceptibility markers DR1, DQw1 or DR4, DQw3. Acting on these findings, we suggest that at least two MHC-class II genes are involved in the pathogenesis of Brazilian pemphigus foliaceus: at least one gene, associated to DR1,DQw1 and to DR4,DQw3, confers susceptibility and at least one gene, associated to DR7,DQw2 and DR3,DQw2, confers resistance. The susceptibility gene(s) seem(s) to be epistatic to or dominant over (if allelic) the resistance gene(s). Both are dominant over other alleles at their locus (or loci).

Space-variant filtering through the Wigner distribution function

Space-invariant and space-variant filtering of discrete images with unidimensional variation is performed in this paper through the Wigner distribution function (WDF). Low-pass, bandpass, and high-pass filtering is used in the Fourier domain and in the Wigner distribution, to compare their different behavior in both cases. A space-variant filter is generated to modify the WDF of an object to obtain, after inversion, a spatially variant filtered image. Finally, spatially variant defocused images generated through the Wigner distribution are restored by Wiener based filters applied in the Wigner domain. The method applied to recover the filtered images can easily be generalized to bidimensional images.

Giant-cell arteritis presenting with ipsilateral hemiplegia and lateral medullary syndrome

We describe the clinical and anatomopathological findings in an 85-year-old male presenting with a lateral medullary syndrome and ipsilateral hemiplegia (Opalski's syndrome) due to giant-cell arteritis of the vertebral artery. Other common associated symptoms of the disease were absent, and the erythrocyte sedimentation rate was only of 30 mm/h. This case emphasizes that limited intracranial giant-cell arteritis may present rarely as a stroke.

Complement activation in Brazilian pemphigus foliaceus

Brazilian pemphigus foliaceus is an autoimmune blistering skin disease of man that has a very high incidence in a confined geographical distribution. Rocket immunoelectrophoresis of plasma showed increased levels of complement fragments, C4d and Ba, indicating activation of complement through both the classical and the alternative pathways. Less sensitive methods such as CH50, total C3 and C4 did not demonstrate this activation, and immune complex measurements were within normal range. While complement may not be absolutely necessary for the development of skin lesions, our longitudinal studies show that activation of complement is at its highest during the most active phase of the disease.

Complement and antibody deposition in Brazilian pemphigus foliaceus and correlation of disease activity with circulating antibodies

Brazilian pemphigus foliaceus is a blistering skin disease endemic to central and southern areas of South America. In this study of skin biopsy specimens from 14 patients we present evidence that complement and immunoglobulins were present by direct immunofluorescence in the epidermal intercellular spaces in all patients. Eight of 14 patients had granular deposits of C3 in the basement membrane zone. By indirect immunofluorescence, serum samples from all 19 patients tested demonstrated the presence of circulating IgG autoantibody. Autoantibodies deposited in the intercellular spaces in titers ranging from 1:10 to more than 1:1280, and the titers drastically decreased during treatment. This is the first study to demonstrate complement deposition in the skin in Brazilian pemphigus foliaceus.

Physicians' diagnoses compared with algorithmic differentiation of causes of jaundice

Clinical data were collected in 194 cases of jaundiced patients treated at the "Adolfo Lopez Mateos" ISSSTE Hospital in Mexico City from July 1985 to July 1986. A copy of the clinical history of each patient was given to each of four physicians--one recently graduated from medical school, another in his first year of gastroenterology, and two others who were experienced gastroenterologists. The same clinical data were processed by a computer set up to use a modified Danish COMIC algorithm. All physicians and the computer technician were blinded to the "gold standard" pathologic diagnoses, with which their diagnoses were compared. Accuracy rates of the physicians in distinguishing intrahepatic (medical) from extrahepatic (surgical) jaundice were 78%, 86%, 86%, and 91%, and the accuracy of computer-assisted diagnoses was 96%. Chi-squared analysis of the diagnoses of three of the physicians and those of the computer showed significant differences (p between 0.1 and 0.01). For the diagnoses of the remaining physician, however, no significant difference was found after chi-squared continuity correction.

Digital restoration models for color imaging

Color images degraded by defocusing and chromatism are restored using different digital models and linear filtering techniques. The restoration process for color images is properly performed through the filters associated with three transfer functions for tristimulus values. However, the use of three monochromatic OTFs corresponding to the maxima of the color receiver is also discussed for different cases of wavelengthdependent aberrations, since it enables a significant reduction in the computer processing time.

Diaphragmatic elevation in stroke

We compared the relative elevations of the two diaphragms in the supine chest films of 62 patients with recent hemiparesis due to a supratentorial stroke with that of 92 acute coronary patients without neurologic disease. Patients with severe hemiparesis or lesions larger than 40 ml exhibited an excessive elevation of the diaphragm on the paretic side compared with controls. This finding was more common with lesions involving the genu of the internal capsule and/or the near anterolateral area. Measurement of the interdiaphragmatic elevation difference may give information on the location and/or size of the stroke.

Recidivism in a cohort of young Australian drinking-drivers

Four hundred and sixty-three men aged 18-25 years were referred to a counselling programme in 1975-1977, after their first conviction for an alcohol-related traffic offence. Records of the Victoria Police, and those of the Motor Registration Board, were searched for subsequent alcohol-related traffic offences up to February 1984. Those subjects who had left the State of Victoria or had died were identified, and a "survival" curve was constructed where survival implied freedom from reconviction for an alcohol-related traffic offence. By means of Cox's proportional hazards model, the rate ratios of a number of predictor variables of recidivism were calculated; those of significance were the number of drinks per week, social class, and a history of "family troubles with drinking". Reduction of alcohol consumption may be a more appropriate goal in programmes that are concerned with the counselling of young drinking-drivers than is attempted modification of the drinking-driving nexus.

Chronic alcoholic proximal wasting: physiological, morphological and biochemical studies in skeletal muscle

Electromyography, muscle histochemistry and assay of all glycolytic enzymes, phosphorylase, glycogen, carnitine and several mitochondrial marker enzymes in skeletal muscle (vastus lateralis) were carried out in two groups. One group comprised chronic alcoholic patients with prominent proximal wasting, the other was an alcoholic group with normal neuromuscular examination. Biochemical results were compared with data from control groups with normal muscle histology and with non-alcohol related type 2b fibre atrophy. Either 2b atrophy factor or 2b variability coefficient were increased in all wasted alcoholic patients, with normal values in alcoholics without wasting. Electromyography studies were usually normal in proximal muscles, although several patients had mild distal neuropathies. A significant fall in activity of phosphorylase and all glycolytic enzymes was found in wasted alcoholics with reference to normal controls. In the non-ethanolic 2b atrophy group the activity of several glycolytic enzymes was also significantly lower, but for each enzyme the mean activity was not depressed to the same extent as in the wasted alcoholic group. Muscle glycogen, carnitine, and mitochondrial marker enzyme activities (isocitrate dehydrogenase, monoamine oxidase, cytochrome oxidase) were normal in alcoholics with proximal wasting. It is concluded that there is no deficiency of mitochondrial marker enzymes in wasted alcoholics and that a significant depression in glycogenolytic and glycolytic enzyme activity is seen which is explained in part, but probably not fully, by 2b fibre atrophy.

Site of bronchodilatation with inhaled ipratropium bromide and fenoterol in normal subjects

To assess the effectiveness and site of action of bronchodilatation with an inhaled anticholinergic bronchodilator, ipratropium bromide, and a beta adrenergic agonist, fenoterol, we measured the density dependence of maximal flow and the density dependence of pulmonary resistance using a digital computerized averaging circuit. Eight normal subjects were studied on two separate days, before and after the bronchodilators were administered in a double blind manner. Both drugs resulted in significant and equivalent bronchodilatation. However, there were no significant changes in the density dependence of maximal flow or pulmonary resistance with either agent. These results in normal subjects, therefore, do not support the hypothesis of a preferential site of action of inhaled anticholinergic agents and beta-adrenergic agents.

Hemodynamic changes from spinal cord stimulation for vascular pain

The hemodynamic changes induced by spinal cord stimulation (SCS) have been studied in a group of 20 patients with peripheral vascular pain. The surgical technique consisted of the introduction of 1 or 2 electrodes in the subarachnoid space up to the level of the painful area, for mono or bipolar SCS. Several techniques have been used for evaluation of hemodynamic changes induced by SCS. Peripheral blood flow speed was measured by means of ultrasound Doppler, showing a raised maximum speed during stimulation, and a tendency of the pulse wave to return to normal. Thermography showed a marked increase of temperature in the painful area. Preoperatively, plethysmography showed an absence of the typical flow waveform, whilst postoperative recordings showed a small wave of progressively increasing amplitude. Scintigraphy with 201TI showed an increase in muscular blood flow in previously hypovascularized areas. The mechanism of action of SCS on peripheral blood flow and vascular pain is discussed.

Peripheral neuropathy in meningococcal septicemia

We report a case of a mixed sensorimotor, predominantly axonal mononeuritis multiplex that developed after a severe meningococcal septicemia and disseminated intravascular coagulation (DIC) with associated distal limb necrosis. Ischemia resulting from the DIC-induced multiple vascular occlusions is suggested as the leading cause of this neuropathy.

Cerebral infarction of the basal ganglia due to embolism from the heart

We studied 8 patients with cerebral infarction in the deep territory of the middle cerebral artery (MCA). All patients had a definite cardiac source of emboli and no known factors for thrombosis. Mixed sensory and motor deficit was found in all but one patient and CT scan showed larger lesions than usually reported in lacunar infarcts. Contrast enhancement was seen in all cases in which CT scan was performed in the second or third week. It is concluded that embolic infarcts in deep cerebral territory of MCA from a cardiac source are more frequent than previously reported. This diagnosis has to be considered when CT scan demonstrates a deep cerebral infarct.

Polymicrobial anaerobic septicemia due to lateral sinus thrombophlebitis

Continuous polymicrobial anaerobic septicemia was the main manifestation of a lateral sinus thrombophlebitis (LST) in a patient who had a history of chronic otitis media. Five different anaerobic microorganisms were isolated in blood cultures. Three of them were also present in ear cultures. The diagnosis was confirmed at surgery and the patient was successfully treated with moxalactam disodium therapy. This case emphasizes that LST should be considered before polymicrobial anaerobic septicemia, especially if there is a history of chronic otitis media.