Case report: C1/2 rotational instability progressing to extreme subaxial hyperkyphosis in an adolescent with severe catatonia

Introduction

Autism spectrum disorder (ASD) is characterized by deficits in social communication, repetitive behaviors, and can be accompanied by a spectrum of psychiatric symptoms, such as schizophrenia and catatonia. Rarely, these symptoms, if left untreated, can result in spinal deformities.

Research question and case description

This case report details the treatment of a 16-year-old male ASD patient with catatonic schizophrenia and mutism, presenting with neck pain, left-rotated torticollis, and fever. MRI revealed atlantoaxial rotational instability and spinal cord compression from a dislocated dens axis. After inconclusive biopsies, empirical antibiotics, hard collar and halo fixation treatment, persistent instability necessitated C1/2 fusion. The ongoing catatonia was addressed with electroconvulsive therapy. Concurrently, he developed severe subaxial hyperkyphosis. The report examines the decision-making between conservative and surgical management for an adolescent with significant psychiatric comorbidity and progressive spinal symptoms against a backdrop of uncertain etiology.

Materials and methods

A case report and review of the literature.

Results

Posterior C1-C7 stabilization was successfully executed, effectively restoring cervical sagittal alignment, which was maintained throughout a two-year follow-up. Concurrently, the catatonia resolved.

Discussion and conclusion

To our knowledge, this is the third reported case of severe cervical deformity associated with fixed posture in a psychiatric patient. This case report emphasizes the critical importance of multidisciplinary collaboration in managing the interplay between neuropsychiatric disorders and severe spinal deformities. It showcases the practicality and efficacy of surgical intervention for persistent cervical deformity in pediatric schizophrenia patients, highlighting the necessity for a comprehensive risk-benefit analysis.

Case report: Psychosis and catatonia in an adolescent patient with adipsic hypernatremia and autoantibodies against the subfornical organ

This is the first description of a patient in which adipsic hypernatremia, a rare autoimmune encephalitis, presented in combination with complex psychiatric symptomatology, including psychosis and catatonia. Adipsic hypernatremia is characterized by autoantibodies against the thirst center of the brain. These autoantibodies cause inflammation and apoptosis in key regions of water homeostasis, leading to lack of thirst and highly increased serum sodium. To date, the symptoms of weakness, fatigue and drowsiness have been associated with adipsic hypernatremia, but no psychiatric symptomatology. Here, we showcase the first description of an adolescent patient, in which severe and complex psychiatric symptoms presented along with adipsic hypernatremia. The patient experienced delusion, hallucinations, restlessness and pronounced depression. Further, he showed ritualized, aggressive, disinhibited and sexualized behavior, as well as self-harm and psychomotor symptoms. Due to his severe condition, he was hospitalized on the emergency unit of the child and adolescent psychiatry for 8 months. Key symptoms of the presented clinical picture are: childhood-onset complex and treatment-resistant psychosis/catatonia, pronounced behavioral problems, fatigue, absent thirst perception, hypernatremia and elevated prolactin levels. This case report renders first evidence speaking for a causal link between the autoimmune adipsic hypernatremia and the psychotic disorder. Moreover, it sheds light on a new form of autoimmune psychosis.

Sleep regularity in healthy adolescents: Associations with sleep duration, sleep quality, and mental health

Current evidence points to the importance of sleep for adolescent physical and mental health. To date, most studies have examined the association between sleep duration/quality and health in adolescence. An emerging line of research suggests that regularity in the timing of sleep may also play an important role in well-being. To address this aspect of sleep, the present study investigated daily variability of sleep, quantified using the sleep regularity index (SRI), in 46 adolescents (M = 12.78 ± 1.07 years) and its association with depressive symptoms/mental health. Sleep was measured during a 6 month period (M = 133.11 ± 36.42 nights) using actigraphs to quantify SRI values calculated for school days, weekends and holidays. Depressive symptoms and general psychopathology were assessed at the beginning (baseline) and end (follow-up) of the actigraphy measurements. Sleep was most regular during school days and associated with a longer total sleep time, shorter sleep onset latency, and higher sleep efficiency. Moreover, a higher SRI on school days was associated with fewer depressive symptoms at follow-up, whereas higher SRI on weekends was associated with less overall psychopathology at follow-up. Furthermore, the change in overall psychopathology, but not depressive symptoms across the two assessments was correlated with sleep regularity index. Our results suggest that regular timing of sleep is associated with sleep that is of longer duration and higher quality and may be protective of adolescent mental health. Therefore, adolescents should be encouraged not only to get enough sleep, but also to retain regular sleeping patterns to promote well-being and mental health.

Sleep and physical activity: results from a long-term actigraphy study in adolescents

PURPOSE

Research to date suggests that physical activity is associated with improved sleep, but studies have predominantly relied on self-report measures and have not accounted for school day/free day variability. To address these gaps in the literature, the aim of the present study was to (a) quantify physical activity in adolescents using long-term daily actigraphy measurement and (b) to examine the association between actigraphically assessed steps and sleep behavior in a sample of healthy adolescents. To be able to capture intra- and inter-individual differences in the daily physical activity of adolescents, we examined within as well as between subjects effects and its association with sleep.

METHODS

Fifty adolescents between 10 and 14 years of age were included in the present study. In total 5989 days of actigraphy measurement (average of 119 ± 40 days per participant; range = 39-195 days) were analyzed. We use multilevel modeling to disentangle the within and between subject effects of physical activity on sleep. In this way, we examine within an individual, the association between steps during the day and subsequent sleep on a day-to-day basis. On the other hand, our between subjects' analysis allows us to ascertain whether individuals with more overall physical activity have better sleep.

RESULTS

Within a subject more steps on school and free days were associated with later bed times on school and free days as well as later rise times on school days only. On the other hand, comparing between subjects' effects, more steps were associated with lower sleep efficiency on free and school days. No other significant associations were found for the other sleep variables.

CONCLUSION

Our results obtained through objective and long-term measurement of both sleep and number of steps suggest weak or non-significant associations between these measures for most sleep variables. We emphasize the importance of the methodology and the separation of within subject from between subject features when examining the relationship between physical activity and sleep.

[Symptomatic testicular metastasis of acinar adenocarcinoma of the prostate]

We report about the rare occurrence of symptomatic testicular metastasis of an acinar adenocarcinoma of the prostate. Testicular metastases are usually incidentally detected in patients treated with bilateral orchiectomy or more often during autopsy. In the literature, there are only a few clinical cases describing symptomatic testicular metastases. However, the possibility of such metastases should be considered in patients diagnosed with advanced prostate cancer. Testicular examination should be performed regularly, even in patients with low prostate-specific antigen levels.

[Multicenter comparison of complications after robot-assisted and open simple prostatectomy]

INTRODUCTION

Robot-assisted simple prostatectomy (RASP) is a relatively new minimally invasive procedure for surgical treatment to manage symptomatic, therapy-refractory benign prostate hyperplasia (BPH) in prostate volumes >80 cm³. Thus, postoperative morbidity based on Clavien-Dindo and hematological parameters in RASP and open simple prostatectomy (OSP) procedures are examined.

PATIENTS AND METHODS

We retrospectively reviewed a total of 78 patients: 39 patients underwent RAPS and 39 OSP. The following parameters were statistically evaluated and compared: age, PSA value, prostate volume, ASA score, duration of hospital stay, operative time, Hb decrease on postoperative (po) day 1 and in the 5 five po days, CRP peak in the first 5 po days and transfusion rate.

RESULTS

The comparison between RASP and standard OSP showed no significant differences regarding the mean patient age (73 vs. 74 years; p =0.54), PSA values (7.7 vs. 10.7 ng/ml; p =0.17), ASA score (2.2 vs. 2.3; p =0.26) and prostate volume (130 vs. 113 cm³; p =0.07). Patients in the RAPAE group had statistically significant longer surgery (178 vs. 110 min; p =<0.01) with a significantly smaller decrease in Hb on po day 1 (1.9 vs. 3.3 g/dl; p ≤0.01) and in the first 5 po days (2.4 vs. 4.2 g/dl; p ≤0.01), lower need for preserved blood (3% vs. 26%; p =0.01) and number of blood bags (0.1 vs. 1.3; p =0.01), a lower po Clavien-Dindo score (0.44 vs. 1.23; p =0.003) and lower CRP values (52 vs. 104 mg/l; p ≤0.01) in the first 5 po days.

CONCLUSION

RASP is a safe procedure that offers the advantage of reduced blood loss and blood bag consumption and rare complications due to the minimally invasive surgical method. The OSP group showed an increased occurrence of complications due to bleeding, leading to prolonged hospitalization and significantly increased need for blood transfusion. The lesser increase of CRP in RASP group is a result of the lower invasiveness of the robot-assisted procedure.

Correction to: The child and adolescent psychiatry: study of training in Europe (CAP‑STATE)

The original article has been corrected.

The child and adolescent psychiatry: study of training in Europe (CAP-STATE)

There is great cultural diversity across Europe. This is reflected in the organisation of child and adolescent mental health (CAMH) services and the training of the respective professionals in different countries in Europe. Patients and their parents will want a high quality, knowledgeable, and skillful service from child and adolescent psychiatrists (CAPs) wherever they see them in Europe. A European comparison of training programs allows all stakeholders in different European countries to assess the diversity and to initiate discussions as to the introduction of improvements within national training programs. Major issues to be addressed in comparing child and adolescent psychiatric training programs across Europe include: (1) formal organisation and content of training programs and the relationship to adult psychiatry and paediatrics; (2) flexibility of training, given different trainee interests and that many trainees will have young families; (3) quality of governance of training systems; (4) access to research; and (5) networking. The Child and Adolescent Psychiatry-Study of Training in Europe (CAP-State) is a survey of training for child and adolescent psychiatrists (CAPs) across European countries. It aims to revisit and extend the survey carried out in 2006 by Karabekiroglu and colleagues. The current article is embedded in a special issue of European Child + Adolescent Psychiatry attempting to for the first time address training in CAP at the European and global levels. Structured information was sought from each of 38 European and neighboring countries (subsequently loosely referred to as Europe) and obtained from 31. The information was provided by a senior trainee or recently qualified specialist and their information was checked and supplemented by information from a senior child and adolescent psychiatry trainer. Results showed that there is a very wide range of provision of training in child and adolescent psychiatry in different countries in Europe. There remains very substantial diversity in training across Europe and in the degree to which it is subject to national oversight and governance. Some possible reasons for this variation are discussed and some recommendations made.

Association between depressive symptoms and sleep neurophysiology in early adolescence

BACKGROUND

Depression is highly prevalent among adolescents, and depressive symptoms rise rapidly during early adolescence. Depression is often accompanied by subjective sleep complaints and alterations in sleep neurophysiology. In this study, we examine whether depressive symptoms, measured on a continuum, are associated with subjective and objective (sleep architecture and neurophysiology) measures of sleep in early adolescence.

METHODS

High-density sleep EEG, actigraphy, and self-reported sleep were measured in 52 early adolescents (12.31 years; SD: 1.121; 25 female). Depressive symptoms were measured on a continuum using the Center for Epidemiological Studies Depression Scale (CES-D). The association between depressive symptoms and 2 weeks of actigraphy, self-reported sleep, sleep architecture, and sleep neurophysiology (slow wave activity and sigma power) was determined via multiple linear regression with factors age, sex, and pubertal status.

RESULTS

Despite no association between polysomnography measures of sleep quality and depressive symptoms, individuals with more depressive symptoms manifested worse actigraphically measured sleep. Less sleep spindle activity, as reflected in nonrapid eye movement sleep sigma power, was associated with more depressive symptoms over a large cluster encompassing temporal, parietal, and occipital regions. Furthermore, worse subjectively reported sleep quality was also associated with less sigma power over these same areas. Puberty, age, and sex did not impact this association.

CONCLUSIONS

Sleep spindles have been hypothesized to protect sleep against environmental disturbances. Thus, diminished spindle power may be a subtle sign of disrupted sleep and its association with depressive symptoms in early adolescence may signal vulnerability for depression.

Equipment-independent reference values for dopamine transporter imaging with 123I-FP-CIT

Aim: Reliable reference values are helpful to interpret and compare the results of dopamine transporter imaging with SPECT. Since semi-quantitative reference values cannot be easily transferred between imaging equipments, this study aimed to establish equipment independent normal values for the true striatal binding of 123I-FP-CIT. Patients, methods: Specific striatal FP-CIT binding of 6 healthy volunteers and 26 patients with essential tremor were used to generate a reference range by applying an equipment specific resolution dependent factor to compensate for recovery effects. This factor has been determined previously by a series of standardized phantom measurements of an anthropomorphic basal ganglia phantom. Herewith, the resulting DAT binding values represent the expected true specific binding in the striatum. Results: On average, true specific striatal binding was 5.83 ± 0.96 in healthy controls, 5.25 ± 0.67 in patients with essential tremor and 5.36 ± 0.75 in the entire study cohort. Conclusion: These preliminary results may serve as a basis for the generation of a generally accepted equipment independent reference range for dopamine transporter imaging with 123I-FP-CIT. By a simple phantom measurement that can be accomplished within one day factors related to specific imaging equipment and processing can be corrected for, resulting in specific binding values which may enable a more standardized interpretation of dopamine transporter scans.

Web-Based Assessment of Mental Well-Being in Early Adolescence: A Reliability Study

BACKGROUND

The ever-increasing use of the Internet among adolescents represents an emerging opportunity for researchers to gain access to larger samples, which can be queried over several years longitudinally. Among adolescents, young adolescents (ages 11 to 13 years) are of particular interest to clinicians as this is a transitional stage, during which depressive and anxiety symptoms often emerge. However, it remains unclear whether these youngest adolescents can accurately answer questions about their mental well-being using a Web-based platform.

OBJECTIVE

The aim of the study was to examine the accuracy of responses obtained from Web-based questionnaires by comparing Web-based with paper-and-pencil versions of depression and anxiety questionnaires.

METHODS

The primary outcome was the score on the depression and anxiety questionnaires under two conditions: (1) paper-and-pencil and (2) Web-based versions. Twenty-eight adolescents (aged 11-13 years, mean age 12.78 years and SD 0.78; 18 females, 64%) were randomly assigned to complete either the paper-and-pencil or the Web-based questionnaire first. Intraclass correlation coefficients (ICCs) were calculated to measure intrarater reliability. Intraclass correlation coefficients were calculated separately for depression (Children's Depression Inventory, CDI) and anxiety (Spence Children's Anxiety Scale, SCAS) questionnaires.

RESULTS

On average, it took participants 17 minutes (SD 6) to answer 116 questions online. Intraclass correlation coefficient analysis revealed high intrarater reliability when comparing Web-based with paper-and-pencil responses for both CDI (ICC=.88; P<.001) and the SCAS (ICC=.95; P<.001). According to published criteria, both of these values are in the "almost perfect" category indicating the highest degree of reliability.

CONCLUSIONS

The results of the study show an excellent reliability of Web-based assessment in 11- to 13-year-old children as compared with the standard paper-pencil assessment. Furthermore, we found that Web-based assessments with young adolescents are highly feasible, with all enrolled participants completing the Web-based form. As early adolescence is a time of remarkable social and behavioral changes, these findings open up new avenues for researchers from diverse fields who are interested in studying large samples of young adolescents over time.

A Cilia Independent Role of Ift88/Polaris during Cell Migration

Ift88 is a central component of the intraflagellar transport (Ift) complex B, essential for the building of cilia and flagella from single cell organisms to mammals. Loss of Ift88 results in the absence of cilia and causes left-right asymmetry defects, disordered Hedgehog signaling, and polycystic kidney disease, all of which are explained by aberrant ciliary function. In addition, a number of extraciliary functions of Ift88 have been described that affect the cell-cycle, mitosis, and targeting of the T-cell receptor to the immunological synapse. Similarly, another essential ciliary molecule, the kinesin-2 subunit Kif3a, which transports Ift-B in the cilium, affects microtubule (MT) dynamics at the leading edge of migrating cells independently of cilia. We now show that loss of Ift88 impairs cell migration irrespective of cilia. Ift88 is required for the polarization of migrating MDCK cells, and Ift88 depleted cells have fewer MTs at the leading edge. Neither MT dynamics nor MT nucleation are dependent on Ift88. Our findings dissociate the function of Ift88 from Kif3a outside the cilium and suggest a novel extraciliary function for Ift88. Future studies need to address what unifying mechanism underlies the different extraciliary functions of Ift88.

Computer-aided transrectal ultrasound: does prostate HistoScanning™ improve detection performance of prostate cancer in repeat biopsies?

Background

An imaging tool providing reliable prostate cancer (PCa) detection and localization is necessary to improve common diagnostic pathway with ultrasound targeted biopsies. To determine the performance of transrectal ultrasound (TRUS) augmented by prostate HistoScanning^TM analysis (PHS) we investigated the detection of prostate cancer (PCa) foci in repeat prostate biopsies (Bx).

Methods

97 men with a mean age of 66.2 (44 – 82) years underwent PHS augmented TRUS analysis prior to a repeat Bx. Three PHS positive foci were defined in accordance with 6 bilateral prostatic sectors. Targeted Bx (tBx) limited to PHS positive foci and a systematic 14-core backup Bx (sBx) were taken. Results were correlated to biopsy outcome. Sensitivity, specificity, predictive accuracy, negative predictive value (NPV) and positive predictive value (PPV) were calculated.

Results

PCa was found in 31 of 97 (32 %) patients. Detection rate in tBx was significantly higher (p < .001). Detection rate in tBx and sBx did not differ on patient level(p ≥ 0.7). PHS sensitivity, specificity, predictive accuracy, PPV and NPV were 45 %, 83 %, 80 %, 19 % and 95 %, respectively.

Conclusions

PHS augmented TRUS identifies abnormal prostatic tissue. Although sensitivity and PPV for PCa are low, PHS information facilitates Bx targeting to vulnerable foci and results in a higher cancer detection rate. PHS targeted Bx should be considered in patients at persistent risk of PCa.

[Endoprosthetic treatment of osteoporosis-related coxarthrosis : aspects of safe patient treatment]

BACKGROUND

With increasing life expectancy the prevalence of osteoarthritis is also substantially rising. Patients aged between 65 and 75 years scheduled for total joint arthroplasty suffer from undetected osteoporosis in 20-25% of cases.

OBJECTIVES

How to determine osteoporosis during preoperative workup? Which conclusions can be drawn for the operation treatment and the postoperative course?

METHODS

The literature dealing with the prevalence of osteoporosis, perioperative complications of total hip arthroplasty, selected register informations, guidelines for diagnostics and treatment of osteoporosis and for the postoperative treatment are summarized and discussed.

RESULTS

The fracture risk is determined according to the guidelines of the Dachverband Osteologie (DVO, Governing Body on Osteology). The implant and the anchorage are selected based on the risk of suffering from osteoporosis. An intraoperative fracture and early aseptic loosening are the main operative risk factors. For the postoperative course in addition to education about arthroplasty, adequate support for prevention of falls is mandatory. Continuous physiotherapy with muscular strengthening is advisable. The long-term medication should be checked for risks in the PRISCUS list of potentially inappropriate medication in the elderly and non-steroidal anti-inflammatory drugs (NSAIDs) should not be prescribed in patients with cardiac comorbidities. Patients with confirmed osteoporosis should be treated with antiresorptive agents.

Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation

In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of 'note bloat'. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.

[Femoral nerve palsy as delayed complication after total hip replacement: delayed hematoma formation in unexpected screw malpositioning]

Nerve injury after total hip replacement is a rare but severe complication. If the nerve lesion becomes evident in the early postoperative phase the lesion is often due to an incorrect implant position, direct nerve injury or vascular injury with manifestation of a hematoma which results in nerve compression. Secondary nerve lesions are more often due to a chronic hematoma with nerve compression. Secondary nerve lesions in particular are often a diagnostic challenge and should lead to an early revision after comprehensive imaging diagnostics.

Nuclear factor of activated T cells mediates oxidised LDL-induced calcification of vascular smooth muscle cells

AIMS/HYPOTHESIS

Vascular calcification is a prominent feature of both atherosclerosis and diabetes, and is clinically associated with osteoporosis. The expression of bone-regulatory factors and the impact of oxidative stress in aortic calcification are well-documented. Recently, nuclear factor of activated T cells (NFAT) cytoplasmic, calcineurin-dependent 1 (NFATc1) was identified in calcified aortic valves and has been implicated in vascular calcification. Therefore, we assessed the mechanisms of osteogenic transdifferentiation of vascular smooth muscle cells induced by oxidised LDL (oxLDL) and evaluated the role of NFAT in this process.

METHODS

Human coronary artery smooth muscle cells (HCASMCs) were cultured for 21 days in medium supplemented with oxLDL. NFAT was inhibited using the NFAT inhibitor VIVIT, or by knockdown with small interfering RNA (siRNA). Osteogenic transdifferentiation was assessed by gene expression, matrix mineralisation and alkaline phosphatase activity.

RESULTS

Exposure to oxLDL caused the transformation of HCASMCs towards an osteoblast-like phenotype based on increased mineral matrix formation and RUNX2 expression. NFATc1 blockade completely prevented oxLDL-induced osteogenic transformation of HCASMCs as well as oxLDL-induced stimulation of osteoblast differentiation. In contrast, matrix mineralisation induced by osteogenic medium was independent of the NFAT pathway. Of note, oxLDL-conditioned medium from HCASMCs transferred to bone cells promoted osteoblast mineralisation. Consistent with these in vitro findings, diabetic rats with a twofold increase in oxidised lipid levels displayed higher aortic calcium concentrations and increased expression of osteogenic markers and production of NFATc1.

CONCLUSIONS/INTERPRETATION

Our results identify the NFAT signalling pathway as a novel regulator of oxLDL-induced transdifferentiation of vascular smooth muscle cells towards an osteoblast-like phenotype.

Equipment-independent reference values for dopamine transporter imaging with 123I-FP-CIT

AIM

Reliable reference values are helpful to interpret and compare the results of dopamine transporter imaging with SPECT. Since semi-quantitative reference values cannot be easily transferred between imaging equipments, this study aimed to establish equipment independent normal values for the true striatal binding of 123I-FP-CIT.

PATIENTS, METHODS

Specific striatal FP-CIT binding of 6 healthy volunteers and 26 patients with essential tremor were used to generate a reference range by applying an equipment specific resolution dependent factor to compensate for recovery effects. This factor has been determined previously by a series of standardized phantom measurements of an anthropomorphic basal ganglia phantom. Herewith, the resulting DAT binding values represent the expected true specific binding in the striatum.

RESULTS

On average, true specific striatal binding was 5.83 +/- 0.96 in healthy controls, 5.25 +/- 0.67 in patients with essential tremor and 5.36 +/- 0.75 in the entire study cohort.

CONCLUSION

These preliminary results may serve as a basis for the generation of a generally accepted equipment independent reference range for dopamine transporter imaging with 123I-FP-CIT. By a simple phantom measurement that can be accomplished within one day factors related to specific imaging equipment and processing can be corrected for, resulting in specific binding values which may enable a more standardized interpretation of dopamine transporter scans.

Die vestibulär evozierten Muskelpotenziale in Abhängigkeit vom nervalen Ursprung und der Lage eines Akustikusneurinoms

INTRODUCTION

Most acoustic neuromas (AN) originate from the inferior vestibular nerve (IVN). Vestibular evoked myogenic potentials (VEMP) are accepted as the only unilateral test for the function of the sacculus and the IVN.

METHODS

The influence of the origin from the IVN and superior vestibular nerve (SVN), and the position of the AN in relation to the internal auditory canal on VEMPs was investigated. A total of 39 patients (aged: 30-67 years, mean: 53 years) were examined. The VEMPs were recorded on the activated sternocleidomastoid muscle and averaged over 200 stimuli. Tone bursts (95 dB nHL; 500 Hz; stimulation rate 5 Hz) were used to generate the VEMPs.

RESULTS

The exact origin of the AN from the SVN or the IVN could be determined intraoperatively and correlated using VEMP in 28 patients.

CONCLUSION

The origin of the AN has only a marginal influence on the results of VEMP measurements. The position of the AN in relation to the internal auditory canal seems to have more influence than the origin.

Measuring unilateral otolith function via the otolith-ocular response and the subjective visual vertical

In the present study, attention is directed to the unilateral response of the otolith system to static and dynamic tilt, as reflected by subjective estimation of the visual vertical (oculogravic perception). Measurements were performed with a variable radius rotary chair, which permits controlled modulation of the centripetal, or radial, acceleration. By limiting the radius, i.e. eccentric displacement of the head by 3.5 cm during constant-velocity rotation about the earth-vertical axis, adequate unilateral stimulation of the otolith organ--predominantly the utricle--is generated, without involving the semicircular canals. This paradigm has been employed to measure the unilateral utriculo-ocular response. In contrast to the otolith-ocular response (OOR), the subjective visual vertical (SVV) reflects the processing of otolithic information in the higher brain centres (thalamus, vestibular cortex). Exploitation of these two complementary approaches provides useful information for both experimental and clinical scientists. The findings also reveal that centripetal acceleratory stimulation during constant angular velocity with the subject centred on axis is sufficient to localize peripheral otolith dysfunction by means of SVV estimation. This represents a novel test of otolith function that can be easily integrated into routine clinical testing.

[Otolith-ocular reflex in linear acceleration of low frequencies]

BACKGROUND

During constant velocity rotation about the earth's vertical axis, eccentric displacement of the head can be used to generate adequate stimulation of the otolith organs. More recently, studies have been performed with a variable radius rotatory chair, which permits a controlled modulation of the centripetal or radial acceleration, to achieve linear acceleration frequencies much lower than with a conventional linear sled.

METHODS

In the present study, frequency response and threshold testing was performed using sinusoidal modulation of the chair radius. Three-dimensional eye movements were recorded with binocular video-oculography.

RESULTS

The gain (0.09 degree/degree at 0.03 Hz, 0.009 degree/degree at 1 Hz) and phase relationships of the otolith-ocular response (OOR) show a low-pass characteristic over the measured range of 0.03-1.0 Hz. In comparison to the flat response of neurophysiological recordings from the otolith afferent, our findings support the idea that any low-pass filtering of otolith afferents occurs at the level of the vestibular nuclei.

CONCLUSION

The OOR could be detected at acceleration levels of 0.03 m/s2, much lower than the subjective threshold for the perception of 0.08 m/s2.

Comparison of the relaxation effect in vitro of nitroglycerin vs. fenoterol on human myometrial strips

AIMS

Substance dose-related comparison of relaxation effect of nitroglycerin (GTN) and the beta 2-mimetic substance fenoterol in human myometrial tissue.

METHODS

Test criterion is the isometric force development of isolated human myometrial strips. These muscle strips were removed from the lower uterine segment at cesarean section. Fenoterol in concentrations of 3 x 10(-8)-10(-5) mol/l or GTN in concentrations of 1.7 x 10(-8)-5.8 x 10(-4) mol/l were applied to the 2 x 2 x 10-mm strips, which were fixed and maintained in tissue baths. The curves were plotted on line. The integral or the "area under the curve" (AUC) served as the parameter for muscle strip activity.

RESULTS

A total of 100 strips from 20 patients were used. GTN demonstrated a significant relaxation effect in the in vitro model on human myometrial strips from pregnant women already treated with oxytocin. The effect was able to be enhanced to a point where oxytocin-induced contractions were completely absent. A relatively clear connection was demonstrated between dose and effect whereby increased muscle relaxation resulted at increased concentrations. Compared to GTN application, muscle strip relaxation was less pronounced under fenoterol; a complete inhibition of myometrial activity was not achieved under fenoterol.

CONCLUSIONS

With respect to relaxation of the myometrial tissue samples the NO donor GTN is at least as potent as the standard tocolytic agent fenoterol in the in vitro model.

Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists

BACKGROUND

The authors undertook a study to determine the prevalence in dentists of abnormal sensory nerve conduction and/or symptoms of carpal tunnel syndrome, or CTS, the most common nerve entrapment syndrome.

METHODS

In a cross-sectional study, dentists (n = 1,079) were screened during the American Dental Association's Annual Health Screening Program in 1997 and 1998 by means of standard electrodiagnostic measures in the dominant hand and a self-reported symptom questionnaire. The authors diagnosed a median mononeuropathy from a 0.5- or 0.8-millisecond, or ms, prolongation of the median sensory-evoked peak latency compared to the ulnar latency. They diagnosed CTS if the subject also had accompanying symptoms of numbness, tingling or pain.

RESULTS

Thirteen percent of screened dentists were diagnosed with a median mononeuropathy (using a 0.5-ms prolongation as the criterion), but only 32 percent of these had symptoms consistent with CTS (4.8 percent overall). When the 0.8-ms prolongation was used as the electrodiagnostic criterion, only 2.9 percent (overall) were diagnosed with CTS. People with diabetes, rheumatoid arthritis and obesity were more likely to have a median mononeuropathy.

CONCLUSIONS

The prevalence of symptoms consistent with CTS in the dominant hand among dentists was higher than the prevalence in the general population. However, when electrodiagnostic confirmation is added, the prevalence of CTS was nearly the same as that among the general population.

CLINICAL IMPLICATIONS

Early recognition of CTS can lead to more effective management. Education regarding ergonomic risk factors can be an effective preventive measure.

Experimental model for local application of growth factors in skin re-epithelialisation

We did an experimental study to assess the effects of different growth factors on re-epithelialisation of skin wounds by creating a partial-thickness defect in rats with a handle dermatome. Three different growth factors that are particularly involved in the re-epithelialisation phase of wound repair (epidermal growth factor (EGF), keratinocyte growth factor (KGF), and basic fibroblast growth factor (FGF-b) n = 10 in each group) were applied locally in a hydrocolloid dressing containing solutions of the different factors (EGF 10 micrograms/ml, KGF 3.3 ng/ml, bFGF 1 microgram/ml). The dressings were changed daily. The thickness of the epithelium, the percentage of re-epithelialisation, and the maturity of the epithelium were quantified and measured morphometrically. The results showed that: the experimental model allowed us to apply the growth factors, while continuously maintaining the dose within the maximum activity of the growth factor; when EGF, KGF, and bFGF were given according to the protocol there was significant thickening of the new epidermis (p < 0.01) and acceleration of the re-epithelialisation (p < 0.05) rate compared with controls, and significantly more mature epithelium grew (p < 0.05) all of which were evident on both the third and the fifth days; and EGF and KGF cause a more epidermal thickening than bFGF.

Role of mast cells in the pathogenesis of postburn inflammatory response: reactive oxygen species as mast cell stimulators

Thermal trauma has a direct effect on mast cells, triggering the secretion of histamine. This secretion leads to an enhanced xanthine oxidase activity and an increased production of reactive oxygen species (ROS), the latter being produced after burns through differing mechanisms. As ROS have been shown to have deleterious effects on cellular membranes, a lesion of the mast cell membrane could close the circle of autoinjury due to the vasoactive actions of mast cell mediators. Our studies were designed to assess the potentiality of ROS as stimulators of mast cell degranulation after burns by comparing two groups of rats treated, respectively, with SOD and saline solution after a scald injury. Plasma levels of tryptase and histamine were analyzed as markers of mast cell activity. A comparison of the mean increases of tryptase between baseline and 3-h postburn levels in the two groups shows significant differences (p < 0.001) (control: 0.13+/-0.04, SOD: 0.03+/-0.01). When comparing the mean increases between the baseline and 3 h postburn levels of histamine in the two groups, significant differences were also found (p < 0.001) (control group: 2.70+/-0.57. SOD group: 1.22+/-0.32). The lower levels of histamine and tryptase induced by SOD provides indirect evidence that ROS are involved in the process, causing the release of such mediators by mast cells, which may in turn suggest that ROS can act as stimulators of mast cell degranulation in burns.

Detection of polycyclic aromatic hydrocarbon degradation genes in different soil bacteria by polymerase chain reaction and DNA hybridization

Twenty different strains of Pseudomonas, Mycobacterium, Gordona, Sphingomonas, Rhodococcus and Xanthomonas which degrade polycyclic aromatic hydrocarbons (PAH) were characterized in respect to genes encoding degradation enzymes for PAH. Genomic DNA from these strains was hybridized with a fragment of ndoB, coding for the large iron sulfur protein (ISP alpha) of the naphthalene dioxygenase from Pseudomonas putida PaW736 (NCIB 9816). A group of seven naphthalene-degrading Pseudomonas strains showed strong hybridization with the ndoB probe, and five Gordona, Mycobacterium, Rhodococcus and Pseudomonas strains able to degrade higher molecular weight PAH showed weaker hybridization signals. Using a polymerase chain reaction (PCR) approach, seven naphthalene-degrading Pseudomonas strains showed a PCR fragment of the expected size with ndoB-specific primers and additionally ten strains of Gordona, Mycobacterium, Pseudomonas, Sphingomonas and Xanthomonas able to degrade higher molecular weight PAH were detected with degenerate primer-pools specific for the ISP alpha [2Fe-2S]-Rieske center of diverse aromatic hydrocarbon dioxygenases. This suggests a molecular relationship between genes coding for PAH catabolism in various PAH-degrading bacterial taxa, which could be used to evaluate the PAH-degradation potential of mixed populations.

Regular physical exercise corrects endothelial dysfunction and improves exercise capacity in patients with chronic heart failure

BACKGROUND

The purpose of this study was to determine the effects of systemic exercise training on endothelium-mediated arteriolar vasodilation of the lower limb and its relation to exercise capacity in chronic heart failure (CHF). Endothelial dysfunction is a key feature of CHF, contributing to increased peripheral vasoconstriction and impaired exercise capacity. Local handgrip exercise has previously been shown to enhance endothelium-dependent vasodilation in conduit and resistance vessels in CHF.

METHODS AND RESULTS

Twenty patients were prospectively randomized to a training group (n=10, left ventricular ejection fraction [LVEF] 24+/-4%) or a control group (n=10, LVEF 23+/-3%). At baseline and after 6 months, peak flow velocity was measured in the left femoral artery using a Doppler wire; vessel diameter was determined by quantitative angiography. Peripheral blood flow was calculated from average peak velocity (APV) and arterial cross-sectional area. After exercise training, nitroglycerin-induced endothelium-independent vasodilation remained unaltered (271% versus 281%, P=NS). Peripheral blood flow improved significantly in response to 90 microg/min acetylcholine by 203% (from 152+/-79 to 461+/-104 mL/min, P<0.05 versus control group) and the inhibiting effect of L-NMMA increased by 174% (from -46+/-25 to -126+/-19 mL/min, P<0.05 versus control group). Peak oxygen uptake increased by 26% (P<0.01 versus control group). The increase in peak oxygen uptake was correlated with the endothelium-dependent change in peripheral blood flow (r=0.64, P<0. 005).

CONCLUSIONS

Regular physical exercise improves both basal endothelial nitric oxide (NO) formation and agonist-mediated endothelium-dependent vasodilation of the skeletal muscle vasculature in patients with CHF. The correction of endothelium dysfunction is associated with a significant increase in exercise capacity.

Subjectless sentences in child Danish

Three alternative accounts of subject omission, pragmatic, processing and grammatical, are considered from the perspective of child Danish. Longitudinal data for two Danish children are analyzed for subject omission, finite and infinitival verb usage and discourse anchorage of sentence subjects (overt and missing). The data exhibit a well-defined phase of subject omission which coincides with a well-defined phase of infinitival verbal utterances. No evidence is found for input driven accounts of subject omission. Danish adults rarely omit subjects from utterance initial position. Neither is there any evidence to support the claim that omitted subjects are anchored in previous discourse. Evidence supporting a processing constraint explanation of missing subjects is equivocal. The pattern of subject omission, infinitival usage and third person pronoun and past tense usage points to a grammatical explanation of the phenomenon. However, current grammatical accounts have difficulty accommodating several aspects of the data reported. Contrary to structure building theories, the Danish children do not exhibit a phase of development where only uninflected verb forms are used. Danish children also omit subjects from finite utterances. Furthermore, the decline of subject omissions in finite utterances coincides with decline in usage of infinitival utterances. These findings challenge tense-based accounts of children's subject omission. Finally, Danish children exhibit an asymmetry in subject omission according to verb type; subjects are omitted from main verb utterances more frequently than from copula utterances. Given the language typology associated with Danish, this asymmetry is difficult to accommodate within truncation and tense or number-based accounts of subject omission. We suggest that a proper treatment of child subject omission will involve an integration of grammatical and discourse-based approaches.

Air evacuation of critically burned patients

We analyze the repercussions of air evacuation on the physiopathology of the critically burned patient based on the experience on 63 patients evacuated by air. Clinical repercussions are due to accelerations, vibrations, noise, and, primarily, to altitude. Accelerations are important during take-off and landing, and vibrations may be important in helicopter evacuations in the presence of craniofacial trauma. The noise, especially in helicopters, can interfere with diagnostic and therapeutic maneuvers in-flight. The altitude modifies atmospheric pressure, partial pressure of oxygen, and water concentration in inhaled air. In the aircraft we use, atmospheric pressure is between 550 and 532 mm Hg at the normal flight altitudes. This situation determines the expansion of body gases. Hypoxia seriously worsens any respiratory insufficiency, primarily in the presence of smoke inhalation. The decrease of water concentration in the inhaled air compels the increase of fluid perfusion. Pre-flight and in-flight measures are analyzed, especially with regard to smoke inhalation, pneumothorax, and parenteral perfusion.

Comparison of the effects of nerve growth factor and superoxide dismutase on vascular extravasation in experimental burns

Superoxide dismutase (SOD), a free-radical scavenger, inhibits the increase of vascular permeability in experimental burn lesions in rats. In this study the aim was to determine whether Nerve Growth Factor (NGF), which has been implicated in the modulation of some inflammatory reactions, behaves in an analogous way. The study compares the haematocrit (Ht) and haemoglobin (Hb) variations in three groups of rats treated respectively with saline solution, SOD and NGF, immediately after causing a 25 per cent dermal burn injury. Statistical comparison (Student's t test) of the Ht and Hb variations between the Control group (Ht and Hb increase) and the NGF group (Ht and Hb decrease), shows significant differences in the intervals between 15 and 60 min (P < 0.01) and between 60 and 120 min (P < 0.05). Although SOD is able to control extravasation in the immediate postburn period (basal-15 min), NGF has a comparable effect in subsequent periods. The overall action of NGF shows that this agent is able to maintain Ht and Hb values at basal levels even after 120 min postburn. These results seem to be the first evidence of an inhibitory effect of NGF on the vascular permeability in burn lesions.

Managing latex allergies in the dental office

The consequences of latex allergy can be serious. This paper details the types of allergic reactions and management strategies for both dental workers and patients.

Assessing treatment decision-making capacity in elderly nursing home residents

Clinicians usually employ indirect measures of cognitive and physical function in order to assess medical decision-making capacity. We tested a reference group of well elderly (Mini-Mental State Exam [MMSE] score = 29.1 +/- 0.8, mean +/- SD), for their understanding of three increasingly complex, hypothetical treatment situations or "vignettes"--use of a hypnotic, need for thoracocentesis, and desire for CPR. From this, we have developed a more direct, Guttman-like assessment of decision-making capacity. Of 51 Veterans Affairs nursing home residents (MMSE score = 22.4 +/- 6.9), only 33.3% demonstrated intact decision-making capacity by this method, whereas 77% were felt by their primary physicians to be capable of giving consent for oral surgery; 37.3% had very impaired decision-making capacity; and 29.4% were intermediate in this ability. Judged against our more direct assessment of decision-making capacity, primary physicians' judgment of capacity for consent was 31% to 39% sensitive in identifying impaired decision-making and the MMSE was 53% to 63% sensitive. These measures were 100% and 82% to 83% specific in identifying intact decision-making capacity, respectively. We conclude that (1) more directly assessed decision-making capacity varies noticeably among elderly nursing home residents and correlates in only limited fashion with frequently used cognitive screening methods; and (2) cognitive screening tests underestimate the prevalence of impaired decision-making capacity in this population. For informed consent and advance directives, our study suggests that decision-making capacity should be directly, rather than indirectly, assessed.