A Collaborative Calibration Study of Reference Materials for Thromboplastins

In a collaborative study of ten laboratories performed mainly within the framework of the BCR (the European Community Bureau of Reference), five thromboplastins were calibrated against the WHO (World Health Organisation) primary international reference preparation 67/40. Of these five thromboplastins, three were BCR reference materials (BCT/099, OBT/79 and RBT/79) and two were WHO secondary international reference preparations (68/434 and 70/178). Human brain tissue type is represented by 67/40 and BCT/099; bovine type by 68/434 and OBT/79, and rabbit type by 70/178 and RBT/79.

The calibration relations are expressed in terms of a linear relationship between the logarithms of the prothrombin times, measured in seconds.

Caspase-3 activity as a prognostic factor in colorectal carcinoma

Several techniques to determine apoptotic frequencies in tumors have been described. In this study, we report that biochemical detection of enzymatic caspase-3 activity is a simple and quantitative technique to measure apoptosis in colorectal tumor cells. The relevance of the level of apoptosis in colorectal cancer for the clinical course remains unclear. Therefore, we studied the correlation between caspase-3 activity and prognosis of the disease in relation to different factors known to be involved in apoptosis induction. High caspase-3 activity significantly correlated with a higher risk of recurrence and was preferentially found in tumors of the right side of the colon. No correlation was detected between high caspase-3 activity and altered protein expression of p53, beta-catenin, or proteins of mismatched repair genes. This indicates that high caspase-3 activity has no evident correlation with the genetic Wnt-signaling or the mismatch repair mutational pathways. The caspase-3 activity significantly correlated with CD57(+) tumor infiltrating cells. Therefore, high caspase-3 activity in right-sided tumors might be induced by a specific lymphocytic reaction.

The relationship between impairments in joint function and disabilities in independent function in children with systemic juvenile idiopathic arthritis

OBJECTIVE

Knowledge about the impact of joint impairment on functional ability is needed in planning care and setting treatment goals in children with juvenile idiopathic arthritis (JIA). We investigated the relationship between joint impairments and upper and lower limb function.

METHODS

Twenty-one children with systemic JIA with an average age of 9.2 years and a mean disease duration of 4.8 years participated in this study. Joint impairments were assessed by the following variables: joint counts on swollen (JCS) and tender (JCT) joints and the loss of joint motion as determined by the Joint Alignment and Motion scale (JAM). Functional performance and functional ability were determined by the Juvenile Arthritis Functional Assessment Scale (JAFAS) and Childhood Health Assessment Questionnaire (CHAQ), respectively. The relationship between impairments and functional disabilities was studied at the level of (1) the complete instruments, (2) upper and lower limb function separately, and (3) the individual joints and items.

RESULTS

Regarding complete instruments, the Spearman rank correlation between functional disabilities and loss of joint motion was moderate to good (JAM/CHAQ rs = 0.66, JAM/JAFAS rs = 0.77). A fair correlation was found between functional disabilities and the joint count on swollen joints (JCS/CHAQ rs = 0.45, JCS/JAFAS rs = 0.52), but no significant relationship was found with the number of tender joints (JCT/CHAQ rs = 0.02, p > 0.05, and JCT/JAFAS rs = 0.14, p > 0.05). At the extremity level (upper and lower limb function), the relationship between functional disabilities and the loss of joint motion appeared to be stronger in the leg than in the arm. At the level of the individual joints and questionnaire items, loss of joint motion in hip or shoulder joint appeared to be the most important factor in predicting limitation in leg or arm function.

CONCLUSION

Our study shows that with respect to joint impairments, loss of joint motion is the strongest indicator of functional disability in children with systemic JIA. Loss of joint motion has a greater effect on lower limb function.

[The ear thermometer; not a good replacement for the rectal thermometer]

OBJECTIVE

To compare the measurements of body temperature with the tympanic infrared thermometer and the digital rectal thermometer.

DESIGN

Prospective, comparative.

SETTING

Beatrix Hospital, Gorinchem, the Netherlands.

PATIENTS AND METHODS

A total of 2057 almost simultaneous measurements of rectal and tympanic temperature were performed in 164 patients in 9 different wards.

RESULTS

The mean difference between the two methods was 0.45 degree C with a standard deviation of 0.57 degree C. The tympanic temperature was lower than the rectal temperature. The differences ranged from -1.5 to 3.6 degrees C. The correlation coefficient was 0.69. If a rectal temperature > 37.8 degrees C was applied as the criterion of fever, the diagnosis was not made in 175/291 measuring moments (60%) with the tympanic thermometer. If a tympanic temperature > 37.8 degrees C was applied as the criterion of fever, the rectal thermometer failed to show fever in 16/132 measuring moments (12%).

CONCLUSION

The low sensitivity of the tympanic measurement to establish fever renders the tympanic infrared thermometer unsuitable for use as a fever thermometer.

Plasma levels of arginine vasopressin elevated in patients with major depression

Mentally healthy subjects show increased plasma concentrations of the neuropeptides, arginine vasopressin (AVP) and oxytocin (OT), under conditions of stress, but data are lacking about plasma concentrations of AVP and OT in patients with major depression. We thus assessed plasma concentrations of AVP and OT in patients with major depression (n = 52) and healthy controls (n = 37). Mean plasma AVP concentrations were higher in the group of depressed patients than in controls. A subgroup of 16 patients showed very high levels of plasma AVP, but no other feature differentiating this subgroup from the other patients was found. In-patients showed higher plasma AVP levels than out-patients, and melancholic patients had higher plasma AVP levels than did nonmelancholic patients. Plasma AVP levels were slightly related to psychomotor retardation and significantly inversely to neuroticism. Patients' plasma OT concentrations had a wider range than in controls. AVP and AVP-mediated functions may be a factor in the clinical picture of depression, possibly by influencing the activity of the hypothalamic-pituitary-adrenal axis.

Beneficial effect of enalapril on left ventricular remodelling in patients with a severe residual stenosis after acute anterior wall infarction

OBJECTIVE

The present study was designed to evaluate the effects of early angiotensin converting enzyme (ACE) inhibition on left ventricular enlargement in patients with anterior wall infarction following reperfusion therapy.

METHODS

Seventy-one consecutive patients with an anterior wall myocardial infarction were randomly allocated to enalapril (n = 36) or placebo (n = 35). All patients received either thrombolytic therapy (n = 46) or underwent primary coronary angioplasty (n = 25). Medication was started within 48 h admission to hospital and continued for 48 weeks. The process of left ventricular remodelling was assessed with two-dimensional echocardiography at 3 weeks and 1 year after the acute onset, and was related to the severity of the residual stenosis of the infarct-related artery.

RESULTS

Baseline left ventricular ejection fraction was 39.2% +/- 8.7%. During the study period left ventricular end-diastolic volume index increased from 48.2 +/- 9.9 ml.m-2 to 54.6 +/- 12.2 ml.m-2 at 3 weeks, and to 59.4 +/- 17.0 ml.m-2 after 1 year I control patients (P < 0.001). In the enalapril-treated patients, left ventricular end-diastolic volume index increased from 50.0 +/- 16.1 to 57.7 +/- 19.3 ml.m-2 at 3 weeks, and to 61.9 +/- 22.7 ml.m-2 after 1 year (P < 0.001). Both at 3 weeks and after 1 year, no overall differences in left ventricular volumes were observed between the enalapril and the placebo group (both ns). However, patients with a residual stenosis severity of > or = 70% in the infarct-related artery (n = 43) showed significant attenuation of remodelling by enalapril (n = 22) when compared to placebo (n = 21). In patients on enalapril, left ventricular end-diastolic volume index increased from 47.0 +/- 13.0 to 53.7 +/- 17.7 ml.m-2 compared to 48.0 +/- 9.6 to 60.3 +/- 16.3 ml.m-2 in control patients (P < 0.03). Also diastolic filling parameters were significantly improved in patients with > or = 70% residual stenosis.

CONCLUSION

In patients with an anterior wall infarction and a severe residual infarct-related coronary artery stenosis following reperfusion, treatment with enalapril prevents the process of left ventricular remodelling. As left ventricular dilatation is an early process we suggest that treatment with ACE inhibition should be started as soon as possible in this group of patients.

Clozapine versus placebo in Huntington's disease: a double blind randomised comparative study

OBJECTIVES

To establish the effect of the atypical neuroleptic clozapine on chorea, voluntary motor performance, and functional disability in patients with Huntington's disease.

METHODS

Thirty three patients with Huntington's disease participated in a double blind randomised trial. A maximum of 150 mg/day clozapine or placebo equivalent was given for a period of 31 days. Assessments were performed in the week before and at the last day of the trial. Chorea was scored using the abnormal involuntary movement scale (AIMS), the chorea score of the unified Huntington's disease rating scale (UHDRS), and judgement of video recordings. Voluntary motor performance was assessed using the UHDRS motor scale. Patients and their partners completed a questionnaire regarding functional disability. Twelve patients already used other neuroleptic medication, which was kept unchanged during the trial period. Results of neuroleptic naive and neuroleptic treated patients were analysed separately.

RESULTS

Clozapine tended to reduce chorea in neuroleptic naive patients only (AIMS); improvement seemed more pronounced in patients receiving higher doses of clozapine. Other measures of chorea (UHDRS chorea score, video ratings) showed no improvement. Clozapine had no beneficial effect on chorea in patients already receiving neuroleptic medication. Voluntary motor performance did not improve with clozapine. Neuroleptic naive patients reported aggravation of functional disability, possibly reflecting the frequent occurrence of side effects. Adverse reactions forced trial termination in six patients and dose reduction in another eight, and consisted mainly of drowsiness, fatigue, anticholinergic symptoms, and walking difficulties.

CONCLUSIONS

Clozapine has little beneficial effect in patients with Huntington's disease, although individual patients may tolerate doses high enough to reduce chorea. Because adverse reactions are often encountered, clozapine should be used with restraint in this patient group.

Tumour necrosis factor alpha gene polymorphisms in rheumatoid arthritis: association with susceptibility to, or severity of, disease?

Genetic factors associated with rheumatoid arthritis (RA) might involve variant tumour necrosis factor (TNF)-alpha genes. Therefore, polymorphisms at positions -308, -238, -376, -163 and +70 relative to the transcription initiation site were studied with respect to the susceptibility to, or severity of, RA. TNF-alpha genotypes of 283 RA patients and 116 healthy individuals were determined. Clinical data were obtained from patient files and questionnaires. The distribution of TNF-alpha alleles was similar in RA patients and healthy controls. With respect to disease severity, the TNF-alpha -238GA genotype was found to be associated with the absence of erosions [odds ratio (OR) 4.1, confidence interval 1.0-17]. In addition, this genotype was associated with a lower number of hand joints affected by erosions within the first 3 yr of disease onset compared to -238GG. The association between the -238 polymorphism and radiographic progression was independent of the presence of HLA-DR4. In line with this observation, the OR for the presence of erosions in patients with both risk factors (DR4 and -238GG) compared to patients who lack these factors was 11.1 (1.8-6.8). No associations between the TNF-alpha -308, +70 and -376 alleles and susceptibility to, or severity of, RA could be demonstrated. Our data indicate that the TNF-alpha -238GA genotype is associated with decreased radiologically detectable progression of RA.

Reproducibility of left ventricular size, shape and mass with echocardiography, magnetic resonance imaging and radionuclide angiography in patients with anterior wall infarction. A plea for core laboratories

After myocardial infarction, left ventricular volume and ejection fraction can be assessed by echocardiography, magnetic resonance imaging and radionuclide angiography to guide therapy and determine prognosis. Whether a measured parameter gives the same results irrespective of the method used and the observer who performs the analysis is only partly known. Intra-observer and inter-observer variability were determined for echo and magnetic resonance imaging. Left ventricular ejection fraction measured by these techniques was related to radionuclide angiograms performed in the same period. Intra-observer variability for both echo and MRI was low and in most instances below 5%. Inter-observer variability for the echo and MRI measurements were substantially higher than intra-observer variability. Comparison of the three imaging modalities revealed systematic differences. Therefore, in clinical studies, left ventricular volume and function parameters have to be measured with the same technique and by the same observer in qualified core laboratories.

An open study of pentoxyfylline and thalidomide as adjuvant therapy in the treatment of rheumatoid arthritis

OBJECTIVE

Dysregulation of tumour necrosis factor alpha (TNF alpha) production is thought to be important in rheumatoid arthritis. Since pentoxifylline and thalidomide inhibit endotoxin induced TNF production in vitro, these drugs were tested in an open study in rheumatoid arthritis patients to assess toxicity, the effect on TNF production, and the antiarthritic effects.

METHODS

12 patients with active rheumatoid arthritis were treated with 1200 mg pentoxifylline and 100 mg thalidomide a day during 12 weeks. In addition, TNF production was assessed by ex vivo whole blood cultures stimulated with endotoxin.

RESULTS

Adverse events such as xerostomia, drowsiness, and constipation occurred in almost all patients, which led to discontinuation in three. The drugs halved the TNF production capacity during treatment (ANOVA, P < 0.03) whereas production capacity of interleukin (IL) 6, IL-10, and IL-12 was not affected. Of the nine patients who completed the study, five fulfilled the ACR-20% response criteria after 12 weeks of treatment.

CONCLUSIONS

Although pentoxifylline/thalidomide reduced the production capacity of TNF, the benefit/side effects ratio was poor due to multiple adverse effects, while clinical observation suggests limited efficacy.

Saccadic eye movements in idiopathic blepharospasm

Visually guided saccades, memory-contingent saccades, and antisaccades were studied with an infra-red reflection technique in 12 patients with idiopathic blepharospasm and in controls. Latencies of the three kinds of saccades were prolonged. Peak velocities and gains did not differ. Our results indicate an initiation defect in the saccadic system, which may be localized in the caudate nucleus.

Echo planar MRI of the heart on a standard system: validation of measurements of left ventricular function and mass

OBJECTIVE

Our goal was to validate cardiac measurements derived from multishot echo planar MRI (EPI) as compared with the well validated conventional GRE technique.

METHOD

Ten healthy subjects underwent breath-hold EPI and non-breath-hold GRE imaging in the short axis orientation of the left ventricle (LV) on a standard 1.5 T MR system. Ten section levels were obtained to encompass the entire LV. Measurements were obtained of end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), LV mass, time to end-systole (TES), and peak filling rate (PFR). Analysis of variance was performed to determine agreement between GRE- and EPI-derived measurements.

RESULTS

The acquisition time for EPI was much shorter than that for GRE (2.5 vs. 15 min). Both imaging techniques yielded good quality images allowing LV volumetrics. Agreement between GRE and EPI was best for measurements of EDV, SV, and LV mass; somewhat less agreement was found for ESV, EF, TES, and PFR. The intraobserver variability for measuring TES and PFR was higher for GRE than EPI (one sided F test; critical values at p = 0.05 were > 3.18).

CONCLUSION

Multishot EPI of the heart provides accurate measurements of LV function and mass in a time-efficient manner.

Pulmonary function and postoperative complications after wedge and flap reconstructions of the main bronchus

Between 1980 and 1989, 8 wedge and 17 flap main bronchoplasties were done in 24 patients (4 carcinoid tumors, 4 benign lesions, 17 carcinomas). Bronchial anastomotic stenoses, pulmonary function, and survival were evaluated. Preoperative ventilation/perfusion scans with preoperative and postoperative spirometry were done in all patients except two who underwent a wedge bronchoplasty. Postoperative bronchoscopy was done in all patients. Follow-up was complete for the patients with carcinoma (N = 17). In the wedge group bronchial anastomotic stenoses occurred in three (38%) of eight patients. All three patients had serious postoperative complications (persistent atelectasis in one, prolonged ventilatory support in two); one patient died and the other two had impaired postoperative pulmonary function. Complete function recovery occurred in only three (38%) of eight patients who underwent wedge bronchoplasty. In the flap group, bronchostenosis occurred in 3 (18%) of 17 patients. The associated complications (mucus retention, minor atelectasis, partial lobar torsion) were mild. Complete pulmonary function recovery occurred in 13 (76%) of 17 patients who had flap bronchoplasty. Actuarial survival, for the patients with carcinoma, was 88%, 47%, and 41% after 1, 3, and 5 years, respectively. The local recurrence rate was 25% (4/16). In our series, flap main bronchoplasties were effective for the resection of bronchial tumors with local involvement of the adjacent main bronchus. Wedge main bronchoplasties, however, were associated with substantial postoperative complications.

Clinical course of patients with idiopathic Parkinson's disease

We determined the variables associated with the progression and duration of illness of patients with Parkinson's disease (PD) and investigated the cause of death. In 474 patients with parkinsonism, who visited the Academic Hospital between January 1, 1960 and August 31, 1993, we did a survival analysis with the following covariates: age at onset, initial symptom (tremor or rigidity/hypokinesia), age at reaching Hoehn and Yahr stage III, dementia-free period, and levodopa treatment. A total of 345 patients with parkinsonism fulfilled the criteria of idiopathic PD; 258 of them were still alive on the closing date of this study. There were significantly more men than women (1.43:1). Medical advice was sought in an earlier stage by men and by patients with tremor as presenting symptom. For patients with rigidity/hypokinesia as first symptom, the duration of illness until reaching Hoehn and Yahr stage III was shorter than for patients starting with tremor alone. If the initial symptom is tremor, patients develop dementia less frequently and later after onset than when tremor is not involved. Reaching Hoehn and Yahr stage III and developing dementia both, limit the patient's survival time. The mortality risk for a patient was found to be increased from the moment levodopa treatment was started as compared to those patients who had not yet started with the treatment. The effect of levodopa on survival could not be disentangled from effects of other factors related to the start of levodopa treatment.

Assessment of left ventricular volume and mass by cine magnetic resonance imaging in patients with anterior myocardial infarction intra-observer and inter-observer variability on contour detection

Remodeling of the left ventricle after myocardial infarction can be documented by calculation of left ventricular volume and mass, using endocardial and epicardial tracings of multilevel multiphase short-axis cine magnetic resonance (MR) imaging series. We assessed left ventricular volume and mass from 8 slices and during 12 phases of the cardiac cycle in seven patients with an anterior wall myocardial infarction; one patient was studied twice, leaving eight MR examinations to be evaluated. Purpose of this study was to assess the intra-observer and inter-observer variability of epicardial volume, endocardial volume, and left ventricular mass from contours manually traced by two independent observers. For the eight MR examinations, epicardial volume was found to be 292 +/- 51 ml (mean +/- SD) at end-diastole, which decreased to 237 +/- 55 ml at end-systole. Endocardial volume was 141 +/- 31 ml at end-diastole, which decreased to 79 +/- 27 ml at end-systole. Left ventricular ejection fraction was 45 +/- 8%. Mean left ventricular mass, when averaged over all patient studies and all phases, was 159 +/- 30 g. Intra-observer and inter-observer variability were found to be 3.5% and 5.2% for endocardial volume, 2.0% and 2.5% for epicardial volume, and 3.6% and 3.6% for left ventricular mass, respectively. The contour analysis showed a statistically significant phase effect in the endocardial contour in the midventricular slices, which was resolved after establishing a more precise definition for the tracing of the endocardial border. In conclusion, left ventricular volume and mass in patients with an anterior wall myocardial infarction can be assessed with high reproducibility and reliability from manual contour tracings. A precise protocol for the definition of endocardial and epicardial contours is required to obtain reproducible and reliable results.

Correlation between the antibody response to influenza vaccine and helper T cell subsets in healthy aging

To investigate the effects of the altered composition of the helper T cell compartment in ageing on the humoral response to influenza vaccine, we investigated correlations between helper T cell subsets and anti-influenza antibody responses in 23 JUNIEUR healthy young and 41 SENIEUR healthy elderly subjects. Naive helper T cell numbers (CD4+ CD45RA+) were negatively correlated with antibody production to two of the four strains investigated in JUNIEURS only. By contrast, memory helper T cell numbers (CD4+CD45ROhi) were positively correlated with in vivo IgG antibody titres to three of the four vaccine strains. Age-related differences in the composition of the helper T cell compartment, however, did not explain the lower IgG antibody response that was observed to two of the four vaccine strains examined.

Effect of ifosfamide treatment on glutathione and glutathione conjugation activity in patients with advanced cancers

Several studies have suggested that the glutathione/glutathione S-transferase (GSH/GST) system is involved in resistance of tumors toward ifosfamide and other cytostatic agents. Besides, ifosfamide metabolites (in vitro) as well as ifosfamide treatment (in vivo) have been shown to decrease cellular GSH availability. In the present study, the in vivo effects of three different ifosfamide treatment schedules on the GSH/GST system were studied in patients with advanced cancers (n = 24): continuous i.v. infusions of 1300 mg/m2 daily for 10 days and 5000 mg/m2/day for 24 h, as well as a 4-h infusion of 3000 mg/m2 daily for 3 days. The GSH/GST system was characterized by administering bromisoval, a probe drug to assess GSH conjugation activity in vivo, as well as by daily monitoring of GSH concentrations in blood cells and plasma. Bromisoval pharmacokinetics was assessed before and at the end of the ifosfamide treatment. Blood cell GSH levels decreased significantly (P < 0.05) during the 3- and 10-day ifosfamide treatment schedules; the 24-h treatment had no effect. The ifosfamide treatment schedules had only minimal effects on bromisoval pharmacokinetics. Assuming that the kinetics of the probe drug provide an accurate reflection of enzyme activity, this suggests that GST activity remains unchanged. Because GSH conjugation of bromisoval enantiomers requires both GST activity and GSH availability, these results also indicate that, despite the 35% decrease in GSH in blood cells of two patient groups, the GSH availability of the cancer patients was not rate-limiting for GSH conjugation of bromisoval enantiomers. If GSH levels in blood cells reflect those in tumors/other tissues, the present results indicate that ifosfamide may be used clinically to decrease GSH levels. However, whether a 35% decrease is sufficient to increase tumor sensitivity toward (other) cytostatics remains uncertain.

Value of 99mTc-IgG scintigraphy in the prediction of joint destruction in patients with rheumatoid arthritis of recent onset

The ability of technetium-99m-labelled polyclonal human immunoglobulin G (99mTc-IgG) scintigraphy to predict joint destruction in patients with rheumatoid arthritis (RA) was investigated in this study. The progression of radiographically determined joint destruction in wrists, hands and feet was compared with the results of physical and laboratory examination, as well as 99mTc-IgG scintigraphy, measured at the beginning of a year-long study on 30 patients with RA of recent onset. The sensitivity of joint swelling in predicting the progression of radiographically determined joint destruction ranged between 57% and 74%. The sensitivity of 99mTc-IgG scintigraphy ranged between 71% and 100%. The specificity and positive predictive value both of joint swelling and 99mTc-IgG scintigraphy were low. Multiple regression analysis showed that for the total joint score, and for the metacarpophalangeal and forefeet joints, progression of radiographically determined joint destruction was primarily predicted by 99mTc-IgG scintigraphy. Joint swelling, ESR and IgM rheumatoid factor did not contribute to this prediction. We concluded that 99mTc-IgG scintigraphy is superior to conventional clinical and laboratory measurements in RA with respect to prediction of joint destruction.

Retrieval from semantic memory may be normal in multiple sclerosis patients: a study of free word association

Increased effort of retrieval from memory is considered to be a feature of cognition in subcortical neurological diseases, such as multiple sclerosis (MS). Free word association provides a means to investigate alterations in automatic and effortful retrieval. Using this procedure we investigated whether in MS free word association would shift from commonality towards idiosyncrasy, as a result of effortful, controlled retrieval. The MS group consisted of a cohort of outpatients, who suffered from chronic but quiescent MS. The patients responded with perfectly normal association patterns. Apparently, impairment of retrieval, or more specifically increased effort of retrieval, from memory does not hold true generally in MS. In patients with obvious physical handicaps (mean Kurtzke DSS = 4 +/- 2) we could not demonstrate abnormal associative processes.

Technetium-99m labelled polyclonal human IgG scintigraphy before and 26 weeks after initiation of parenteral gold treatment in patients with rheumatoid arthritis

OBJECTIVE

To determine effectiveness of technetium-99m labelled polyclonal human immunoglobulin G (99mTc-IgG) scintigraphy to monitor variation in arthritis activity in patients with rheumatoid arthritis (RA).

METHODS

The results of semiquantitative 99mTc-IgG scintigraphy were compared with those of examination before and 26 weeks after initiation of parenteral gold treatment in 19 patients with RA.

RESULTS

Clinical and laboratory variables of arthritis activity as well as the scores of 99mTc-IgG scintigraphy were significantly lower after gold treatment compared to the scores before treatment. However, the difference between the mean scores of 99mTc-IgG scintigraphy before and after treatment was statistically significant for more joints than such difference in scores for joint pain and joint swelling.

CONCLUSION

99mTc-IgG scintigraphy is able to reflect variations in arthritis activity in patients with RA.

Hypokinesia in Parkinson's disease: influence of age, disease severity, and disease duration

The aim of this cross-sectional study was to compare the role of aging in measures reflecting diurnal activity and immobility in 60 parkinsonian patients with predominant features of hypokinesia and rigidity and 100 healthy subjects aged 50 to 98 years. In the patients, we also studied the relation between disease duration and subjective and objective measures of disease severity. Motor activity was recorded during 5 successive days at home with a wrist-worn activity monitor. For each subject, two mean measures reflecting the diurnal activity level and the relative proportion of activity and immobility were calculated. Diurnal measures of activity revealed in both groups a prominent absolute reduction of activity and an increase of the time spent without movement ("immobility") with advancing age. Parkinsonian patients showed significantly lower values for both motor-activity measures than did the healthy subjects. The rate of the age-related decline of both diurnal activity measures in both groups, however, is comparable. Disease duration showed no relation with subjective and objective measures reflecting disease severity. This study shows that if care is taken to control for disease severity, the rate of the age-related decline of measures reflecting diurnal activity and immobility is similar in both groups. The lack of relation between disease duration and subjective and objective measures of disease severity suggests that the rate of progression of Parkinson's disease can be reliably studied only by means of longitudinal studies.

Determinants of vibration perception thresholds in IDDM and NIDDM patients

The relative influence of diabetes mellitus-related and physiological factors on vibration perception thresholds was assessed in 353 patients in a hospital-based setting (173 insulin-dependent and 180 non-insulin dependent patients, aged 51.1 +/- 15.9 years) and 80 healthy controls (aged 43.3 +/- 15.2 years) employing a Biothesiometer. Vibration perception thresholds were bilaterally measured at the thumbs, medial malleoli and halluces. Sixty (17.0%) older patients had off-scale thresholds (> 50 V). As no systematic side differences were found, values of contralateral sites were averaged. Considering the effects of age, height, gender and skin temperature in controls, age accounted for 46.7 and 52.2% threshold variance at the ankles and halluces, respectively, while height explained 5.1 and 5.1%, respectively. At the thumbs, only age was of relevance. Age relationships with vibration thresholds in health did not differ from published reports at any site. In the patient group, influences of age, height, gender, skin temperature, years from diagnosis, HbAlc, serum creatinine, drop in systolic blood pressure on standing, and ankle/arm blood pressure indices were assessed for each type of diabetes. For both types, age and height again had relevant effects at the lower extremities as did age and gender at the thumbs. Skin temperature was only marginally significant at the halluces of NIDDM patients. Of the disease-related factors, HbAlc had the strongest effect: for both IDDM and NIDDM higher levels were associated with lower vibration sensitivity. Increasing disease duration led to significantly higher thresholds in IDDM patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Low incidence of childhood celiac disease in The Netherlands

The incidence and prevalence of celiac disease vary internationally. We studied the incidence of identified cases of childhood celiac disease in six Dutch provinces that cover 47.9% of the surface area and 67.6% of the total population of The Netherlands. Children with celiac disease aged 0-14 y, diagnosed from January 1975 to January 1991, were traced by 1) contacting all pediatricians in this area, 2) examining the date of the Dutch National Medical Registration, and 3) investigating the membership records of the Dutch Celiac Disease Society. These data were cross-checked by the Dutch Network and National Database of Pathology. Of the 97.9% of pediatricians who answered our inquiry, 46.1% were treating celiac patients. A total of 342 celiac patients were identified. Informed consent that permitted examination of their medical files was given by 97.3% of the parents of the celiac children. The mean crude incidence rate of diagnosed childhood celiac disease, calculated per 1000 live births per year, was 0.18. However, a significant increase in reported incidence was demonstrated from 0.10 in 1976 to 0.32 in 1990. The best estimate, for the years 1985-1990, is 0.22/1000 live births, which is much lower than in most European countries.

Sleep disruption in Parkinson's disease. Assessment by continuous activity monitoring

OBJECTIVE

To assess differences in activity and immobility during sleep between patients with Parkinson's disease (PD) and healthy subjects and to evaluate the relations of clinical variables with the motor activity measures in patients with PD.

DESIGN

Survey, case series.

SETTING

University hospital outpatient neurology department and urban population in Leiden, the Netherlands. Motor activity was recorded during 6 successive nights at home with a wrist-worn activity monitor.

PARTICIPANTS

Eighty-nine patients with PD and 83 age-matched healthy controls.

MAIN OUTCOME MEASURES

For each subject, three mean measures reflecting activity or immobility during the nocturnal period were calculated.

RESULTS

Compared with the healthy elderly subjects, patients with PD have an elevated nocturnal activity level and an increased proportion of time with movement, indicating a more disturbed sleep. The mean duration of nocturnal immobility periods was similar for both groups. This measure, however, did reflect the self-reported disturbed sleep maintenance in both groups. The daily dose of levodopa or the use of dopamine agonists in patients not receiving levodopa, rather than disease severity, proved to be the best predictors of nocturnal activity.

CONCLUSIONS

We hypothesize that in mildly to moderately affected patients with PD, levodopa or dopamine agonists cause sleep disruption by their effects on sleep regulation. In more severely affected patients, the beneficial effects of these drugs on nocturnal disabilities that cause sleep disruption in PD prevail.

In vivo tensile testing of fluorapatite and hydroxylapatite plasma-sprayed coatings

A tensile test has been developed to test bioactive coating materials. Hydroxylapatite (HA) and fluorapatite (FA) coatings with various roughnesses were tested using sandblasted titanium (Ti) as a control material. Twelve goats received 7 implants each for 6 (2 goats), 12 (5), and 24 (4) week implantation periods. After 12 weeks the mean tensile strength values were highest for polished hydroxylapatite (HAP) followed by HA > FAP (polished fluorapatite) > FA > Ti, and hydroxylapatite type coatings were found to exhibit significantly higher values than fluorapatite type coatings or titanium implants. After 24 weeks no statistically significant differences could be found between any of the implant types. The order of the mean strength values was now HAP > HA > FA > FAP > Ti. Fracture always occurred between the coating and titanium if bone contact had been established. In conclusion, it is suggested that results from different types of test methods cannot be used to compare different types of bioactive coatings.

Joint scintigraphy for quantification of synovitis with 99mTc-labelled human immunoglobulin G compared to late phase scintigraphy with 99mTc-labelled diphosphonate

The ability of scintigraphy with technetium 99m-labelled polyclonal human immunoglobulin G (99mTc-IgG) to detect and quantify arthritis activity was studied in 24 patients with RA and in 10 patients with OA. The results of 99mTc-IgG scintigraphy were compared with those of scintigraphy with 99mTc-labelled hydroxymethylene-diphosphonate (HDP). The mean joint scores of 99mTc-IgG scintigraphy in RA patients with active disease were significantly higher (P < 0.001) than the mean scores in patients with inactive disease. The mean joint scores were also higher in patients with erosions compared to those in patients without erosions (P < 0.05). For 99mTc-HDP scintigraphy no significant differences were found between the mean joint scores of these patient groups. Comparison of scintigraphic results between patients with RA and OA revealed that the mean joint score of 99mTc-IgG scintigraphy was significantly (P < 0.001) higher in the patients with RA than in patients with OA, whereas for 99mTc-HDP scintigraphy this difference was not significant. These results show that 99mTc-IgG scintigraphy, when compared to 99mTc-HDP scintigraphy, is a more specific method of detecting synovitis and, also, shows differentiation between different degrees of arthritis activity in RA.

Variability of the main sequence

PURPOSE

This study investigated the relationship between amplitude and peak velocity of saccadic eye movements (the so-called main sequence) and the intra-individual variability of the main sequence.

METHODS

Saccadic amplitudes and peak velocities were measured twice in 58 healthy subjects with an infrared reflection technique.

RESULTS

Considerable intra-individual variability was found between the first and second recordings.

CONCLUSIONS

Intra-individual variability of saccadic peak velocity affects the interpretation of changes in repeated recordings of peak velocities, such as before and after medication is administered. Furthermore, considerable intra-individual variability decreases the probability that statistically significant differences between patients and control subjects can be detected, especially when groups are small. Calculating the intraclass correlation coefficient allows the number of subjects in comparative studies to be determined.

99Tcm-labelled polyclonal human immunoglobulin G scintigraphy before and after intra-articular knee injection of triamcinolone hexacetonide in patients with rheumatoid arthritis

The ability of 99Tcm-labelled polyclonal human immunoglobulin G (99Tcm-IgG) scintigraphy to monitor intra-individual variation in arthritis activity was studied in seven patients with rheumatoid arthritis (RA). These patients were treated with an intra-articular injection of 20 mg triamcinolone hexacetonide. The results of semiquantitative 99Tcm-IgG scintigraphy were compared with the degree of joint swelling and the histological changes observed in synovial biopsies before and 14 days after the injection. In all seven patients the local treatment resulted in a decreased arthritis activity of the treated knee as measured clinically or histologically. This decrease was parallelled, in all patients except one, by a lower uptake of 99Tcm-IgG after the injection when compared to uptake prior to treatment. This study shows that 99Tcm-IgG scintigraphy is able to reflect intra-individual variations in arthritis activity in patients with RA.

Sleep, excessive daytime sleepiness and fatigue in Parkinson's disease

The objective of this questionnaire-based survey was to evaluate the prevalence and causes of sleep disturbances in 90 nondepressive patients with Parkinson's disease (PD) and 71 age-matched healthy subjects. We also assessed the prevalence and characteristics of excessive daytime sleepiness (both groups) and excessive fatigue (PD patients). A high prevalence of sleep disturbances in PD patients was found; this is to a large extent probably the result of aging. As compared with controls, patients had a more severely disturbed sleep maintenance because of nycturia, pain, stiffness, and problems with turning in bed. The prevalence of excessive dreaming is similar in both groups, but altered dream experiences almost exclusively occurred in PD. Patients rated themselves more often to be morning-types than controls. This finding may account for the reported adaptation effects in experimental settings and the reduced REM latency in PD patients. The prevalence of daytime sleepiness was similar in both groups. Excessive daytime sleepiness showed a clear diurnal pattern with a peak in the early afternoon. As for excessive fatigue, the majority of the patients did not report a preferential time for this symptom. Our findings further argue against an association of fatigue with any circadian factor, and instead suggest a relationship with the motor deficits of PD.

The influence of a standard meal on Sinemet CR absorption in patients with Parkinson's disease

We studied the influence of dietary protein intake on the plasma level profile of levodopa, carbidopa, and 3-O-methyldopa and clinical efficacy in 12 patients with idiopathic Parkinson's disease after intake of one levodopa-carbidopa 200/50 controlled release tablet (Sinemet CR; LC-CR). The tablet was given 1 h before the protein rich meal on one day (fasted) and together with the meal on an other day (non-fasted). Higher levodopa and carbidopa concentrations were reached when the LC-CR was taken 1 h before the meal, but the plasma level profile for levodopa was flatter in the non-fasted state. The area under the curve for levodopa was slightly higher in the fasted condition. For the clinical variables walking and tapping slightly better clinical results (P = 0.08) were found in the fasted condition with the higher levodopa levels. If the patient on levodopa is in a clinically satisfactory condition, then non-fasted condition could be preferred because of the smooth plasma level profile demonstrated. However, if the initial levodopa concentrations are not in the critical range to be effective for the patient, the advice should be to take the drug in a fasted condition.

Nocturnal activity and immobility across aging (50-98 years) in healthy persons

OBJECTIVE

To measure the influence of age on measures of nocturnal activity and immobility in 100 healthy subjects aged 50 to 98 years.

DESIGN

Cross-sectional study.

SETTING

Urban population in Leiden. Recordings were performed at home while the subjects maintained their habitual 24-hour pattern of activities.

PARTICIPANTS

100 subjects without a history of major medical disorders and a normal neurological examination and performance-oriented assessment of gait (Tinetti).

MEASUREMENTS

Motor activity was recorded during six successive nights with a wrist-worn activity monitor. The occurrence of supra-threshold motor activity was recorded over 15-second epochs. A questionnaire was used to evaluate sleep habits and the occurrence of sleep disturbances. Four mean measures reflecting activity or immobility during the nocturnal period were calculated for each subject.

RESULTS

Only one out of four measures, (ie, the nocturnal proportion of time with movement, increased with age for females. For males, no age effects emerged. The mean duration of nocturnal immobility periods was higher in females than in males. Also, for females, the use of hypnotics increased with successive decades. Sex and the use of hypnotics were significantly related to the mean duration of immobility periods.

CONCLUSION

If care is taken not to confound aging with illness, measures of nocturnal activity and immobility reveal only marginal effects of aging.

Diurnal effects of motor activity and fatigue in Parkinson's disease

Wrist motor activity was monitored continuously in 65 patients with Parkinson's disease (PD) to assess the influence of disease severity and excessive fatigue on the diurnal motor activity pattern. Mildly or moderately affected PD patients had a similar diurnal pattern to that of 68 healthy controls, with a late morning peak; however, mean levels of motor activity were lower. The most severely affected patients showed an overall flattened diurnal pattern. Results refute the existence of end of day deterioration, but instead suggest a "depressed morning start" in the most severely affected patients with PD. Excessive fatigue was not reported at a particular time of day and did not influence the diurnal motor activity pattern.

Left ventricular measurements with cine and spin-echo MR imaging: a study of reproducibility with variance component analysis

The authors studied the reproducibility of repeated measurements of left ventricular volumes, weight, and wall stress as determined with cine and spin-echo magnetic resonance (MR) imaging. Two observers analyzed 40 serial MR imaging examinations twice, yielding a total of 160 repeated measurements. Estimates of 95% ranges for change were ejection fraction, 10% and 12%; wall mass, 16% and 21%; and wall stress, 22% and 20%, for measurements derived from cine MR imaging and spin-echo MR imaging, respectively. Reproducibility was not significantly different between cine and spin-echo MR imaging. Intraobserver, interobserver, and interexamination errors were quantitated with variance component analysis. Interexamination variability was the single most important contributor to total variance. Reproducibility of left ventricular chamber volume measurements with MR imaging is superior to that of other imaging modalities. In addition, MR imaging can provide reliable estimates of wall mass and wall stress. Efforts to improve reproducibility should be aimed at lowering interexamination variability.

Quantitative assessment of parkinsonian patients by continuous wrist activity monitoring

The aim of this study was to examine the quantitative relationship between activity monitor measures and clinical scores of patients with Parkinson disease (PD). Motor activity was recorded continuously for 5 to 6 days at home with a wrist-worn activity monitor in 69 PD patients and 59 healthy controls. Clinical scores of the patients, age, and sex were submitted to multiple regression analysis to examine the quantitative relationship with measures reflecting the activity level and the proportion of activity and immobility over time. The patients' age, sex, and scores representing hypokinesia and rigidity and resting tremor explained approximately 50% of the variance of the motor activity measures. All motor activity measures declined with age; the rate of decline was similar for the patients and controls. Sex emerged as a predictor of the motor activity measures in the patients only. Male patients with PD showed significantly lower values for all motor activity measures than female patients and controls. Our results show that activity monitoring can be used as an objective quantitative assessment in PD.

Ambulatory activity monitoring during sleep: an evaluation of internight and intrasubject variability in healthy persons aged 50-98 years

The aim of this study was to assess the internight and intrasubject variability of nocturnal activity and immobility measures of 99 healthy subjects aged 50-98 years. Motor activity was recorded at home during 6 successive nights with a wrist-worn activity monitor. The occurrence of suprathreshold motor activity was recorded over 15-second epochs. For each subject, six mean measures reflecting activity or immobility during sleep and their coefficient of variation were calculated. Our results revealed no first-night effect or day-of-week effect of the activity and immobility measures over the 6 nights across all subjects. On the other hand, for all nocturnal activity and immobility measures, a considerable intrasubject variability across the 6 nights was found. Females had a greater intrasubject variability of the mean duration of immobility periods and the movement index than males. The intrasubject variability of all nocturnal activity and immobility measures across the successive age groups remains stable. These findings emphasize that although a first-night effect may be lacking, the intrasubject variability of activity and immobility measures across several nights may still be considerable.

A histological and histomorphometrical investigation of fluorapatite, magnesiumwhitlockite, and hydroxylapatite plasma-sprayed coatings in goats

Plasma-sprayed ceramic coatings of fluorapatite (FA), magnesiumwhitlockite (MW), and hydroxylapatite (HA), and noncoated Ti-6Al-4V alloy (Ti) implants were evaluated histologically and histomorphometrically in a goat animal study. Cylindrical Ti-6Al-4V plugs were plasma-spray-coated with FA, MW, and HA. Noncoated, grit-blasted Ti plugs served as controls. The plugs were implanted into the right femur and left humerus of 20 adult goats. The results were evaluated using descriptive histology and histomorphometry. The histomorphometry consisted of measurements of bone apposition and coating thickness. The results demonstrated that FA showed a high amount of bone apposition without signs of degradation or dissolution. MW showed considerable reduction in thickness and at 12 weeks an adverse tissue reaction. However, at 25 weeks the amount of bone apposition was significantly increased compared with the 12-week implants. HA revealed considerable and progressive reduction in thickness and at 25 weeks a lower amount of bone apposition than FA and MW. At 12 weeks the Ti implants did reveal bone apposition, although frequently localized fibrous tissue was visible. At 25 weeks the Ti implants did not differ in bone apposition from the HA implants. Further studies are necessary on the effect of degradation or dissolution of HA on the compatibility with bone.

The distribution of o,p'-DDD (mitotane) among serum lipoproteins in normo- and hypertriglyceridemia

We found that the distribution of the lipophilic chemotherapeutic agent o,p'-DDD (mitotane) among serum (lipo)proteins was altered in hypertriglyceridemia, with relatively more o,p'-DDD accumulating in the chylomicron and very-low-density lipoprotein (VLDL) fraction. Intralipid, an artificial chylomicron emulsion, or isolated VLDL could extract o,p'-DDD from the other serum (lipo)proteins. There was an inverse relationship between the relative amount of o,p'-DDD found in the fraction exhibiting a density of less than 1.006 g/ml (chylomicrons plus VLDL) and the relative amount observed in the LDL or HDL fractions of serum. Our results indicate that hypertriglyceridemia may impede the entry of o,p'-DDD into the brain or the adrenals. For therapeutic monitoring of o,p'-DDD levels in severe hypertriglyceridemia, we recommend that the chylomicron and VLDL fraction first be removed from the serum by ultracentrifugation.

A mechanical investigation of fluorapatite, magnesiumwhitlockite, and hydroxylapatite plasma-sprayed coatings in goats

Ceramic coatings of fluorapatite (FA), magnesiumwhitlockite (MW), and hydroxylapatite (HA), and noncoated Ti-6Al-4V alloy (Ti) implants were evaluated before and after implantation in an animal study. Cylindrical plugs were coated by plasma-spraying with FA, MW, and HA. X-ray-diffraction patterns showed for FA and HA a crystalline and for MW an amorphous-crystalline coating structure. The plugs were implanted into the right femora and left humeri of 16 adult goats. Follow-up periods were 12 and 25 weeks. The in vivo results were evaluated using push-out tests and scanning electron microscopy. There were significant differences in push-out strengths between femur and humerus. The FA and HA implants showed significantly higher push-out strengths than the MW and Ti alloy implants, especially for the 12 week follow-up period. Furthermore, at 12 weeks, MW showed significantly lower push-out strengths than Ti alloy. SEM-investigation of the interfaces revealed that FA did not degrade while both MW and HA showed extensive degradation at 12 and 25 weeks. In addition, the interface after push-out testing showed for the MW, HA, and Ti alloy implants to be fractured at the implant-tissue interface and for the FA to be fractured at the coating-titanium interface.

Diurnal variation of essential and physiological tremor

Evaluations were made of the diurnal variations of tremor power at rest, after fatigue and after mass loading, and plasma norepinephrine in patients with familial essential tremor and normal subjects. Diurnal tremor power rhythms for both essential and physiological tremor pursued identical temporal profiles. Plasma norepinephrine levels followed a congruent diurnal pattern with later peak values than the peak values of tremor power. Sympathetic nervous system activity is unlikely to be the cause of diurnal tremor power variation. The consistent diurnal rhythm of tremor power may affect dosage schemes of tremorolytic drugs.

The acute and chronic antihypertensive effects of ketanserin cannot be explained by blockade of vascular serotonin, type 2, receptors or alpha 1-adrenergic receptors

The mechanism underlying the antihypertensive effect of acute and chronic administration of ketanserin was investigated in eight hypertensive patients. Intrabrachial artery infusions of serotonin and the selective alpha 1-adrenergic receptor agonist methoxamine were given before and 1 hour after a single oral dose of 20 mg ketanserin and after 4 weeks of treatment with 20 to 40 mg twice daily. Blood pressure was reduced by ketanserin both after the initial dose (p less than 0.01) and after 4 weeks of treatment (p less than 0.01). During placebo, serotonin, 1 ng/kg/min, increased forearm blood flow by 51% +/- 9% (p less than 0.01), whereas the highest dose induced a decrease in flow (-33% +/- 6%; p less than 0.01). Methoxamine elicited a vasoconstriction (p less than 0.001). These effects of serotonin and methoxamine were not influenced by either the initial dose of ketanserin or after 4 weeks of treatment. It is concluded that serotonin cannot be considered a general endogenous pressor agent in these patients. The antihypertensive effects of ketanserin cannot be attributed to either vascular alpha 1-receptor or serotonin, type 2, receptor blockade.

Transient loss of consciousness: the value of the history for distinguishing seizure from syncope

We studied 94 consecutive patients (age 15 or over) to investigate which aspects of the history and clinical findings help to distinguish seizures from syncope and related conditions. Clonic movements or automatism observed by an eyewitness classified an event as a seizure. The seizure group consisted of 41 patients and the syncope group of 53 patients. The likelihood ratio was used to calculate the predictive power of single findings and logistic regression to analyse combinations of findings. The best discriminatory finding was orientation immediately after the event according to the eyewitness and the age of the patient in the absence of an eyewitness report (P less than 0.001). We found a seizure five times more likely than syncope if the patient was disoriented after the event and three times more likely if the patient was less than 45 years of age. Nausea or sweating before the event were useful to exclude a seizure. Incontinence and trauma were not discriminative findings.

SPECT in the diagnosis of Alzheimer's disease and multi-infarct-dementia

SPECT with Tc-99m HM-PAO as a radiopharmaceutical was performed in 17 patients meeting research criteria for Alzheimer's disease (AD), in 10 patients with a clinical diagnosis of multi-infarct-dementia (MID) and in 12 healthy volunteers. Regional tracer uptake was measured in frontal, parietal, and temporoparietal regions. A statistically significant decrease of tracer uptake in the temporoparietal region was found in AD-patients compared with controls. AD-patients showed less activity in this region than MID-patients, but this difference did not reach statistical significance. In both AD- and MID-patients decrease of tracer uptake was not correlated with dementia severity. We conclude that SPECT brain imaging is not yet ready for routine use in the distinction between AD and MID.

Submersion in The Netherlands: prognostic indicators and results of resuscitation

STUDY OBJECTIVES

To analyze prognostic indicators and the outcome of resuscitation in submersion victims (drowning and near drowning).

DESIGN

Retrospective study.

SETTING

Intensive and Respiratory Care Unit. Between January 1, 1979, and December 31, 1985, 87 submersion victims were admitted. The files of 83 victims were available for statistical analysis. There were 66 male victims and 17 female victims; the average age was 31.4 +/- 25.8 years. There were ten salt water and 73 fresh water submersions.

MEASUREMENTS AND MAIN RESULTS

Predictors for better survival potentials were a young age, submersion of less than ten minutes, no signs of aspiration, and a central body temperature of less than 35 C at admission. We did not detect factors that accelerated a decrease in core body temperature at admission and assume that lethal hypoxia had preceded protective hypothermia in our submersion victims. The Orlowski score had a predictive value but at the same time we found nonindependent indicators in this score. Neurologic outcome in our patients, who were not treated according to a brain protection protocol, was not worse than the outcome published by authors who have used such a protocol. Thirty-three percent of the victims with a cardioventilatory arrest (15) and all victims with a ventilatory arrest (11) survived resuscitation and were discharged. Five nonarrest victims died due to late complications.

CONCLUSION

This study shows that no indicator at the rescue site and in the hospital is absolutely reliable with respect to death or survival.

Cognition in patients with multiple sclerosis After four years

This study reports on a 4-year follow-up of cognitive functioning in 33 MS patients and 18 healthy control subjects. As a group, and in agreement with the results in the previous assessment. MS patients have significantly weaker performances than controls in motor speed, reaction time, learning tasks, reading aloud and figure copying. Tasks addressing visuospatial problem solving, behavioural flexibility, and linguistic aspects of oral and written communication do not distinguish between the two groups. Influence of impaired movement is acknowledged in performances utilising speech and reading under instructions of speed, and in figure copying. Cognition per sé remained undisturbed in 25 patients (76%). A uniform MS-related development of cognitive deficits could not be identified, improvement, stability and further deterioration being found at reassessment.

Response fluctuations in Parkinson's disease

We studied the influence of several factors on the occurrence of response fluctuations in 91 Parkinson's disease patients. These included the age at onset, the presenting symptom, the duration of illness, and the stage of the disease at the time of initiation of levodopa treatment as time-independent covariates, and the mean and last dosage of levodopa as time-dependent covariates. Taken separately, none of the factors was related to the occurrence of response fluctuations. We found no evidence to delay levodopa treatment to a later stage of the disease. In the analysis of the combined influence of the age at onset and the interval before levodopa treatment, we noted a tendency for response fluctuations to occur less frequently in those patients with age at onset of 60 years and over who had started levodopa treatment more than 2 years after the 1st symptom. Our analysis of the combination of time-dependent factors suggests that response fluctuations are a likely event in those patients in whom the course of the disease recently necessitated an increase in the dosage of levodopa.

Memory and learning in outpatients with quiescent multiple sclerosis

In 22 (56%) of 39 quiet-stage multiple sclerosis (MS) patients with at least average intelligence quotients, performances in memory and learning tasks were normal, as compared with those of a control group (24 healthy volunteers). Of the remaining 44% (n = 17), 2 patients were amnesic and 5 had been judged to have suffered cognitive decline. Auditory word learning was particularly vulnerable; however, acquisition rate was not significantly different between MS patients and controls.

Treatment of children with central precocious puberty by a slow-release gonadotropin-releasing hormone agonist

A total of 82 patients (74 girls, 8 boys) are presently participating in an international multicentre trial for treatment of central precocious puberty (CPP) with a slow release gonadotropin-releasing hormone (GnRH) agonist depot preparation: Decapeptyl-Depot (DD). Of these patients, 53 (3 boys) were previously untreated (group 1) and 29 (5 boys) have been treated before with either a short-acting GnRH analogue or cyproterone acetate (group 2). Fifty-one patients (44 girls, 7 boys) were treated with DD for 12 months or more. Basal plasma luteinizing hormone (LH) levels decreased in both groups after 1 year of therapy. The LH response to intravenous GnRH was reduced in both groups. Basal plasma follicle stimulating hormone (FSH) levels decreased in both groups. Stimulated FSH levels were reduced in both groups after 1 year of DD treatment. Plasma oestradiol levels in the girls decreased to prepubertal levels in both groups. In all patients the clinical signs of precocious gonadarche such as breast development and menstruations (girls) and an increased testis volume (boys), did not further progress and sometimes regressed in several patients. Growth velocity decreased in the girls of group 1 from 9.0 +/- 0.72 cm/year (mean +/- SEM) in the last half-year before treatment to 6.3 +/- 0.50 in the first half-year of treatment (P less than 0.01) and to 4.5 +/- 0.23 cm/year in the second half-year (P less than 0.01). After 12 months a stabilization of growth velocity was observed.(ABSTRACT TRUNCATED AT 250 WORDS)