Polypharmacy and risk of fractures in older adults: A systematic review

BACKGROUND

Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association.

METHODS

We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, abstracts, and full texts, then performed data extraction and quality assessment.

RESULTS

Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose-response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high.

CONCLUSIONS

Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.

Accelerometry to measure physical activity in toddlers: Determination of wear time requirements for a reliable estimate of physical activity

Accelerometry is widely used to evaluate physical activity in toddlers however recommendations regarding wear time are needed to understand physical activity behaviours in this age group. This study aimed to determine the minimum wear time to reliably evaluate physical activity in toddlers. Children from the 3D Birth Cohort (n = 255, 49.8% boys, 2.1 ± 0.2 years) were asked to wear an accelerometer (GT3X+, ActiGraph) for 7 days. Physical activity was expressed in active time (min/day) and counts per minute (CPM). Single day intraclass correlation coefficients (ICCs) were calculated to assess the effect of varying minimal wear time on reliability estimates. The Spearman-Brown formula was used to determine wear time required to achieve reliability levels of 70%, 80% and 90%. For active time, a reliability of 72.1% was achieved with wearing the accelerometer for ≥ 4 days of ≥ 6 h, which comprised 85.9% of the sample. For CPM, ≥ 4 days of ≥ 6 h provided a reliability of 74.7% and comprised 85.9% of the children. Results differed slightly when girls and boys were analysed separately, but restricting analyses to children with a weekend day did not. In summary, a minimum of 4 days with ≥ 6 h of accelerometry data provides a reliable estimate of physical activity in 2-year toddlers.

Platelet Reactions and Immune Processes

We have studied the interaction between gammaglobulin, complement and several surfaces, in view of gaining a better insight into the molecular mechanisms of the platelet-surface interaction :

1. Glass, polystyrene latex, carbon, kaolin and celite particles are known platelet-activating surfaces. All these surfaces activated complement when coated with gammaglobulin. Collagen however did not show complement fixing ability.

2. Bentonite and betamethasone acetate particles also fixed complement when coated with gammaglobulin.

3. The mechanism of complement fixation induced by these various surface-gammaglobulin complexes was found to be very similar to the reactions induced when immune complexes fix complement.

4. The diverse mechanisms of activation of IgG molecules and the various biological and immunochemical properties of activated IgG are reviewed and discussed.

5. The view is presented that many non-immune as well as immune activators of platelet reactions have in common the ability to activate complement; the possible significance of this property and the role of IgG activation in the induction of platelet reactions are discussed.

Platelet Reactions and Immune Processes

We have studied the effect of complement inhibitors of various classes on platelet aggregation induced by collagen or by latex. The majority of the complement inhibitors which we studied inhibited collagen- or latex-induced platelet aggregation.

The possible role of complement as a mediator in the activation of platelet reactions is discussed.

These findings indicate that some chemicals are able to act on some of the immune reactions and also on platelet thrombogenetic reactions. It is suggested that drugs or combination of drugs having such a polyvalence might be of particular benefit in thrombo-immuno-inflammatory conditions.

Influence of maternal physical activity on infant's body composition

BACKGROUND

Physical activity (PA) during pregnancy might contribute to reduce neonatal adiposity, a predictor of metabolic disturbances.

OBJECTIVE

The objective of the study was to evaluate the association between maternal PA intensity and neonatal body composition.

METHODS

Maternal PA measured by accelerometry and nutrition were documented during pregnancy, as well as neonatal body composition by dual-energy X-ray absorptiometry following delivery. Associations between PA at 17 and 36 weeks (time spent in moderate PA (MPA), vigorous PA (VPA) status and their interaction) and neonatal body composition were addressed by multivariate regression analyses.

RESULTS

From 104 women, 50 (48%) and 16 (18%) performed VPA at 17 and 36 weeks of pregnancy. Performing VPA at either time was associated with a decreased birthweight (BW), while only VPA at 17 weeks decreased neonatal adiposity (fat percentage: -2.3 ± 0.8%, p = 0.003). MPA at 36 weeks was associated with an increased lean mass (2.0 ± 0.8 g per min day^-1 , p = 0.012). Significant interactions were found for BW and bone mineral content (BMC). MPA at 17 weeks tended to increase BW, but not BMC, in the no VPA strata. By contrast, high levels of MPA (≥112 min d^-1 ) combined with VPA at 17 weeks reduced neonatal BMC and BW compared with no VPA (BMC: -5.4 ± 2.0 g, p = 0.008, BW: -302.8 ± 83.7 g, p = 0.0003). Differences were not significant with low MPA levels.

CONCLUSIONS

Exercise intensity modulates neonatal body composition. The long-term significance of a reduced BW, adiposity and BMC with VPA requires further study.

Ralstonia mannitolilytica in cystic fibrosis: A new predictor of worse outcomes

Background

Patients with Cystic Fibrosis are subject to repeated respiratory tract infections, with recent increasing isolation of unusual pathogens. Ralstonia species have lately been isolated at our institution, an organism historically frequently misidentified as Burkholderia or Pseudomonas. The prevalence of Ralstonia spp. in cystic fibrosis populations has yet to be determined, along with its clinical implications.

Case presentations

Seven patients out of the 301 followed at our cystic fibrosis clinic have had Ralstonia strains identified in their respiratory tract. Most strains identified were multi-drug resistant. After aquisition of Ralstonia spp., the patients' clinical course was characterized by more frequent and more severe respiratory infections along with prolonged hospitalizations, greater decline of lung function, and greater mortality. The mortality rate in this group of patients was 86%. No other factor that could explain such a dramatic evolution was identified upon review of patient data. Some of the strains involved were recognized as clones on Pulse Field Electrophoresis Gel, raising the question of person-to-person transmission.

Conclusion

New pathogens are identified with the evolution of the microbiota in cystic fibrosis respiratory tracts. In our cohort of patients, acquisition of Ralstonia spp. was associated with dramatic outcomes in terms of disease acceleration and raised mortality rates. It is of critical importance to continue to better define the prevalence and clinical impact of Ralstonia in cystic fibrosis populations.

CYSTIC FIBROSIS AND ANTIBIOTIC HYPERSENSITIVITY: PRESENT KNOWLEDGE AND PRACTICAL APPROACH

Cystic fibrosis is one of the most common fatal genetic diseases (1 in 2500 births). The defect causing the disease is localized on the 7q31 gene, which codifies for the CFTR (Cystic Fibrosis Transmembrane Conductance Regulator) transmembrane protein. CFTR is a chloride channel localized on the epithelial cells of the mucosa of the respiratory tract, pancreatic ducts, biliary tree, intestine, vas deferens and sweat glands. More than 2000 different mutations are currently known; some are prominent or relatively frequent, ranging from one population to another. The most frequent complications of cystic fibrosis are those affecting the bronchial tree. Patients suffer from recurrent lung infections, which involve a progressive loss of lung function. The pulmonary infections are frequent or chronic and limit the quality of life of patients. In addition to being enormously exposed to antibiotics, they have many more opportunities to develop hypersensitivity reactions to these molecules. Only a complete allergy work-up with a detailed analysis of the clinical history, skin tests and provocation test can show if the patient has actually experienced an allergic hypersensitivity reaction. Desensitization is to be considered as a treatment that may help patients benefit from antibiotic treatment in those cases in which they have a proven allergy to a certain molecule.

Nitrogen potential recovery and concentration of ammonia from swine manure using electrodialysis coupled with air stripping

The practice of intensive animal production in certain areas has resulted in excessive manure production for the available regional land base. Consequently, there is a need to develop treatment technologies to recover the valuable nutrients that manure contains so that the resulting product can be transported and used as fertilizer on agricultural land. The project presented here used electrodialysis in a dilution/concentration configuration to transfer the manure ammonia in the diluate solution by electromigration to an adjacent solution separated by an ion-exchange membrane under the driving force of an electrical potential. Then, air stripping from the electrodialysis-obtained concentrate solution without pH modification was used to isolate the ammonia in an acidic solution. An optimal process operating voltage of 17.5 V was first determined on the basis of current efficiency and total energy consumption. During the process, the swine manure pH varied from 8.5 to 8.2, values favourable for NH(4)(+) electromigration. Total ammonia nitrogen reached 21,352 mg/L in the concentrate solution, representing approximately seven times the concentration in the swine manure. Further increases in concentration were limited by water transfer from the diluate solution due to electroosmosis and osmosis. Applying vacuum to the concentrate reservoir was found to be more efficient than direct concentrate solution aeration for NH(3) recuperation in the acid trap, given that the ammonia recuperated under vacuum represented 14.5% of the theoretical value of the NH(3) present in the concentrate solution as compared to 6.2% for aeration. However, an excessively low concentrate solution pH (8.6-8.3) limited NH(3)volatilization toward the acid trap. These results suggest that the concentrate solution pH needs to be raised to promote the volatile NH(3) form of total ammonia nitrogen.

Sonographic target sign and rim enhancement on magnetic resonance imaging in metastatic melanoma to the breast

We report a target sign on ultrasound and peripheral rim enhancement on gadolinium (Gd)-enhanced MRI images in metastasis to the breast from melanoma. These classic signs, as reported in the liver (ultrasound target sign) and in primary breast cancers (Gd rim enhancement), are probably also of value in cases of metastatic lesions to the breast.

Amino acid and insulin signaling via the mTOR/p70 S6 kinase pathway. A negative feedback mechanism leading to insulin resistance in skeletal muscle cells

Amino acids have emerged as potent modulators of the mTOR/p70 S6 kinase pathway. The involvement of this pathway in the regulation of insulin-stimulated glucose transport was investigated in the present study. Acute exposure (1 h) to a balanced mixture of amino acids reduced insulin-stimulated glucose transport by as much as 55% in L6 muscle cells. The effect of amino acids was fully prevented by the specific mTOR inhibitor rapamycin. Time course analysis of insulin receptor substrate 1 (IRS-1)-associated phosphatidylinositol (PI) 3-kinase activity revealed that incubation with amino acids speeds up its time-dependent deactivation, leading to a dramatic suppression (-70%) of its activity after 30 min of insulin stimulation as compared with its maximal activation (5 min of stimulation). This accelerated deactivation of PI 3-kinase activity in amino acid-treated cells was associated with a concomitant and sustained increase in the phosphorylation of p70 S6 kinase. In marked contrast, inhibition of mTOR by rapamycin maintained PI 3-kinase maximally activated for up to 30 min. The marked inhibition of insulin-mediated PI 3-kinase activity by amino acids was linked to a rapamycin-sensitive increase in serine/threonine phosphorylation of IRS-1 and a decreased binding of the p85 subunit of PI 3-kinase to IRS-1. Furthermore, amino acids were required for the degradation of IRS-1 during long term insulin treatment. These results identify the mTOR/p70 S6 kinase signaling pathway as a novel modulator of insulin-stimulated glucose transport in skeletal muscle cells.

Modulation of corticospinal excitability during imagined knee movements

In this study, we investigated corticospinal excitability during mental simulation of a leg extension movement with the technique of transcranial magnetic stimulation. Motor evoked potentials were recorded in both knee extensors (quadriceps) and flexors (biceps femoris) in 19 trained participants (healthy volunteers). The amplitude and latency of motor evoked potentials were compared in three conditions: (1) at rest, (2) during motor imagery, and (3) at rest, immediately after motor imagery. The results showed a significant effect (p < 0.001) of conditions on motor evoked potentials amplitude in the quadriceps but not in the biceps femoris. During motor imagery, the size of motor evoked potentials in the quadriceps increased significantly (p < 0.001) compared with rest and post-imagery conditions. Changes in motor evoked potentials latency across conditions were not significant, however. These results are consistent with previous studies in the upper limb and suggest that corticospinal excitability can be enhanced during motor imagery to facilitate responses in specific lower limb muscles.

Defective insulin-induced GLUT4 translocation in skeletal muscle of high fat-fed rats is associated with alterations in both Akt/protein kinase B and atypical protein kinase C (zeta/lambda) activities

The cellular mechanism by which high-fat feeding induces skeletal muscle insulin resistance was investigated in the present study. Insulin-stimulated glucose transport was impaired ( approximately 40-60%) in muscles of high fat-fed rats. Muscle GLUT4 expression was significantly lower in these animals ( approximately 40%, P < 0.05) but only in type IIa-enriched muscle. Insulin stimulated the translocation of GLUT4 to both the plasma membrane and the transverse (T)-tubules in chow-fed rats. In marked contrast, GLUT4 translocation was completely abrogated in the muscle of insulin-stimulated high fat-fed rats. High-fat feeding markedly decreased insulin receptor substrate (IRS)-1-associated phosphatidylinositol (PI) 3-kinase activity but not insulin-induced tyrosine phosphorylation of the insulin receptor and IRS proteins in muscle. Impairment of PI 3-kinase function was associated with defective Akt/protein kinase B kinase activity (-40%, P < 0.01) in insulin-stimulated muscle of high fat-fed rats, despite unaltered phosphorylation (Ser473/Thr308) of the enzyme. Interestingly, basal activity of atypical protein kinase C (aPKC) was elevated in muscle of high fat-fed rats compared with chow-fed controls. Whereas insulin induced a twofold increase in aPKC kinase activity in the muscle of chow-fed rats, the hormone failed to further increase the kinase activity in high fat-fed rat muscle. In conclusion, it was found that GLUT4 translocation to both the plasma membrane and the T-tubules is impaired in the muscle of high fat-fed rats. We identified PI 3-kinase as the first step of the insulin signaling pathway to be impaired by high-fat feeding, and this was associated with alterations in both Akt and aPKC kinase activities.

Prevention of skeletal muscle insulin resistance by dietary cod protein in high fat-fed rats

In the present study, we tested the hypothesis that fish protein may represent a key constituent of fish with glucoregulatory activity. Three groups of rats were fed a high-fat diet in which the protein source was casein, fish (cod) protein, or soy protein; these groups were compared with a group of chow-fed controls. High-fat feeding led to severe whole body and skeletal muscle insulin resistance in casein- or soy protein-fed rats, as assessed by the euglycemic clamp technique coupled with measurements of 2-deoxy-D-[(3)H]glucose uptake rates by individual tissues. However, feeding cod protein fully prevented the development of insulin resistance in high fat-fed rats. These animals exhibited higher rates of insulin-mediated muscle glucose disposal that were comparable to those of chow-fed rats. The beneficial effects of cod protein occurred without any reductions in body weight gain, adipose tissue accretion, or expression of tumor necrosis factor-alpha in fat and muscle. Moreover, L6 myocytes exposed to cod protein-derived amino acids showed greater rates of insulin-stimulated glucose uptake compared with cells incubated with casein- or soy protein-derived amino acids. These data demonstrate that feeding cod protein prevents obesity-induced muscle insulin resistance in high fat-fed obese rats at least in part through a direct action of amino acids on insulin-stimulated glucose uptake in skeletal muscle cells.

Development and application of a biological peptide pump for the study of the in vivo actions of angiotensin peptides

In the past few years, a great deal of interest has been focused on the possibility that angiotensin peptides could have direct effects on target tissues independent of their hemodynamic effects. In addition, there has been much speculation on the potential biological roles of angiotensin peptides other than angiotensin II. Unfortunately, a direct test of these possibilities in whole animals has been difficult due to limitations in existing biological systems. In this review, we describe the characteristics of an engineered protein capable of directing the production of a wide variety of peptides to specific tissues and cell types in transgenic animals and discuss its potential applications.

New short peptide substrates of endothelin-converting enzyme and characterization of the enzyme

Endothelin (ET) is a 21 amino acid peptide produced following the cleavage of its precursor, big ET, by a metalloprotease, the endothelin-converting enzyme (ECE). In the study reported here we determined the minimal peptide sequence of big ET necessary for enzyme recognition and cleavage at the P1-P1' site. Furthermore, we have explored the role of the amino acids found at the boundaries of the cleavage site. To reach these goals. we synthesized a series of fragments, all containing the P1-P1' cleavage site, Trp21-Val22. Following the incubation of peptide fragments with a partly purified bovine ECE preparation and after analyzing the cleavage pattern by high-performance liquid chromatography (HPLC), we were able to identify big ET(18-23) amide as the minimal peptide core recognized and cleaved by the enzyme. This hydrolysis was inhibited by phosphoramidon but not by thiorphan, a characteristic of the ECE metalloprotease. However, none of the shorter peptides was able to inhibit the cleavage of big ET-1 by ECE, suggesting that they are not recognized by the enzyme. Particularly, it appears that aspartic acid 18 is a key residue for the recognition phenomenon. The delineation of the minimal structure will be a useful tool to further characterize ECE.

Genotype/phenotype correlations in aniridia

PURPOSE

To detect and characterize mutations in cases of familial and sporadic aniridia in Maritime Canada, and to look for indications of genotype/phenotype correlation within the cohort.

METHODS

Twelve consecutive and unrelated patients (probands) who had total or nearly complete absence of irides, and four affected relatives, were recruited from Maritime Canada. Clinical data were obtained by chart review and electroretinogram testing. Mutations in the PAX6 gene were detected by single-strand conformation polymorphism and characterized by sequence analysis.

RESULTS

Eleven different PAX6 mutations, 10 of which are novel, were found. The four patients with congenital cataracts all had mutations in the C-terminal proline-serine-threonine (PST)-rich domain of the PAX6 protein. Electroretinograms of nine of 11 patients displayed depressed scotopic maximum response b-wave amplitudes. The greatest decrease in b-wave amplitudes was seen in patients in whom the paired domain was disrupted by mutation.

CONCLUSION

Some aspects of the phenotype of aniridia appear to correlate with the predicted effect of point mutations on the paired and PST domains of the PAX6 protein.

Effects of PAX6 mutations on retinal function: an electroretinographic study

PURPOSE

To investigate the retinal function in aniridic patients with documented PAX6 mutations to determine the range of electroretinogram abnormalities in aniridic patients and to relate electroretinogram findings with specific PAX6 mutations.

METHODS

Eleven patients with typical aniridia and fully characterized PAX6 mutations underwent electroretinography.

RESULTS

In all 11 patients, electroretinogram recordings were abnormal, ranging from mild to severe. Rod-related and cone-related activities were equally affected. The amplitude of the oscillatory potentials was the most reduced, followed by the b-wave, then to a milder degree the a-wave. Mutations affecting the paired domain of the PAX6 protein had the biggest impact on the electroretinogram amplitudes. Implicit times were increased in a subgroup with mutations affecting only the homeodomain.

CONCLUSION

Patients with aniridia have varying degree of retinal dysfunction, ranging from severely abnormal to almost normal. The paired domain appears to have more impact on retinal function than other regions of the PAX6 protein. It is unclear whether mutations affecting the homeodomain lead to alteration of the photoreceptor function.

Neuronal encoding of texture changes in the primary and the secondary somatosensory cortical areas of monkeys during passive texture discrimination

Two rhesus monkeys were trained to discriminate, with the use of passive touch, a standard surface [rectangular arrays of raised dots with a spatial period (SP) of 2 mm across the rows and columns] from three modified surfaces in which the SP between rows was increased to 3, 4, or 5 mm over the second half of the surface. After the surface presentation (to digit tips 3 and 4 of one hand) the monkeys indicated the presence or absence of a change in texture by pulling or pushing a lever, respectively, with the opposite hand. Of 193 neurons recorded from primary somatosensory cortex (SI, 3 hemispheres) and 94 neurons from secondary somatosensory cortex (SII, 1 hemisphere), all contralateral to the stimulated hand, the discharge of 51 SI and 19 SII neurons was classified as texture related. Two types of texture-related responses were obtained. Graded neurons showed a linear relationship between mean discharge frequency and SP; nongraded neurons showed a significant change in discharge over the modified half of the surfaces but the discharge did not distinguish between the three modified surfaces. The distribution of these texture responses was significantly different in SI and SII: whereas most of the texture-related neurons in SI (44 of 51, 86%) were graded, the majority of those in SII (12 of 19, 63%) were nongraded. The results were interpreted as suggesting that the nongraded responses reflect feature extraction in SII, signaling the presence of a change in texture but not its magnitude, and so support the notion that texture signals are processed sequentially, first in SI and then in SII.

Cortical mechanisms underlying tactile discrimination in the monkey. I. Role of primary somatosensory cortex in passive texture discrimination

1. The discharge patterns of 359 single neurons in the hand representation of primary somatosensory cortex (SI) of two monkeys (Macaca mulatta) were recorded during the performance of a passive texture discrimination task with the contralateral hand (104 in area 3b, 149 in area 1, and 106 in area 2). Three nyloprint surfaces were mounted on a drum that was rotated under the digit tips. One surface was entirely smooth, whereas the other two were smooth over the first half and rough over the second half (smooth/ rough) (raised dots, 1 mm high and 1 mm diam, in a rectangular array; spatial period of 3 mm across the rows and columns for most recordings; 9 mm between columns for selected recordings). The monkeys were trained to distinguish between the smooth and smooth/rough surfaces. After the surface presentation, the monkey indicated the texture of the second half of the surface by pushing or pulling, respectively, on a lever with the other arm. For most recordings an average tangential speed of 49 mm/s was tested. For selected recordings motor speed was incremented (63, 75, or 89 mm/s). 2. Two hundred eighty-three neurons had a cutaneous receptive field (RF) on the hand (96 in area 3b, 120 in area 1, and 67 in area 2). Thirty-five neurons had a deep RF (4 in area 3b, 15 in area 1, and 16 in area 2). Seven neurons had mixed cutaneous and deep RFs (4 in area 1, 3 in area 2). Thirty-four neurons had no identifiable RF (4 in area 3b, 10 in area 1, and 20 in area 2). 3. The discharge of 185 of 359 neurons was significantly modulated during the presentation of one or both surfaces compared with the discharge at rest. Cells with a cutaneous RF that included part or all of the distal phalangeal pads of the digits used in the task (usually digits III and IV) were more likely to be modulated during surface presentation (132 of 179, 74%) than those with a cutaneous RF not in contact with the surfaces (24 of 104, 23%). The remaining neurons (mixed, deep, or no RF) were also infrequently modulated (29 of 76, 38%). 4. Of the 185 modulated units, 118 cells were classified as texture related because there was a significant difference in the discharge rate evoked by the smooth/rough and smooth surfaces. Cells with a cutaneous RF that included the digital pads in contact with the surfaces were frequently texture related (100 of 132, 76%). Texture sensitivity was less frequently observed in the remaining modulated neurons (18 of 53, 34%: cutaneous RF not in contact with the surfaces, deep RF, mixed cutaneous and deep RF, no identifiable RF). 5. Texture-related neurons were found in areas 3b, 1, and 2. Two patterns of texture-related responses were observed in the 100 cutaneous units with an RF in contact with the surfaces. Thirty-one units were classified as showing a phasic response at the time the digits encountered the leading edge of the rough half of the surface. Fifty-eight cells were classified as phasic-tonic (or sometimes tonic at the slowest motor speeds) because the response lasted for the duration of the presentation of the rough portion of the surface. The remaining 11 neurons could not be readily classified into one or the other category and, indeed, generally showed clear texture-related responses only at higher motor speeds (> 49 mm/s, 9 of 11). 6. Speed sensitivity was systematically evaluated in 41 of 100 texture-related units with a cutaneous RF in contact with the surfaces. The discharge of 66% of the units (27 of 41) varied significantly with the speed of surface presentation, with discharge increasing at higher speeds. Speed sensitivity was found in all three cytoarchitectonic areas (6 of 6 cells in area 3b, 11 of 22 in area 1, and 10 of 13 in area 2). 7. Contact force was also systematically monitored in these experiments (69 of 100 texture-related cells with a cutaneous RF in contact with the surfaces). Linear regression analyses indicated than 22% (15 of 69) of the texture-related units were sensitive to contact force (13

Visual evoked potentials with crossed asymmetry in incomplete congenital stationary night blindness

PURPOSE

To investigate a proposed postretinal defect in patients with the incomplete form of congenital stationary night blindness (CSNB2) and to compare visual evoked potential (VEP) results with those found in various forms of albinism.

METHODS

Visual evoked potentials were performed in 10 patients with a diagnosis of CSNB2, 10 subjects with albinism, and 17 normal subjects. Visual evoked potentials were elicited monocularly with diffuse flash stimulation. Scalp electrodes were placed over each hemisphere and referred to the forehead. Interhemispheric bipolar recordings were derived, and the correlation coefficient (CC) was calculated for various segments of the interhemispheric responses.

RESULTS

A crossed visual evoked potential asymmetry pattern could be demonstrated in 9 of 10 patients with CSNB2. All subjects with albinism and none of the normal subjects showed the crossed asymmetry pattern. Statistical comparison of the CC computed for various segments of the interhemispheric response shows that the pattern of inversion in CSNB2 is more prominent in the 25 to 100 msec range (median CC, -0.37) and in the 175 to 250 msec range (CC, -0.27). In subjects with albinism, all segments show a negative CC (range, -0.46 to -0.60). In normal subjects, all segments are positively correlated (range, 0.36 to 0.66).

CONCLUSIONS

Crossed visual evoked potential asymmetry was found in patients with CSNB2; therefore, excessive decussation, as demonstrated by this testing procedure, should not be considered as pathognomonic for albinism.

The electroretinographic diagnosis of the incomplete form of congenital stationary night blindness

Fifteen patients with the incomplete form of congenital stationary night blindness (iCSNB) were reviewed to better characterize their electroretinographic (ERG) findings in view of differential diagnosis with other retinal conditions also presenting with negative bright-flash ERG responses. In all 15 patients, in dark-adapted conditions, the bright-flash ERG response had a normal a-wave followed by a subnormal b-wave. Oscillatory potentials (OPs) observed on the ascending limb of the b-wave, although delayed in implicit time, were of large amplitude. The response to a long-wavelength stimulus showed cone-related components and some well-delineated OPs. On the other hand, the photopically elicited cone responses were strongly abnormal, with a subnormal a-wave followed by a barely recordable b-wave. No OPs could be elicited under photopic conditions. The cone related components and the OP characteristics clearly distinguish iCSNB from the complete form of CSNB and other retinal conditions presenting with minimal fundus abnormalities but with negative bright-flash ERG responses, such as found in Duchenne muscular dystrophy and Aland Island eye disease. The severely abnormal post-synaptic components in the photopic recordings contrast with the well-differentiated cone activity evoked in scotopic conditions. We propose a cone system that does not respond optimally under the normal operating range (photopic) but rather under mesopic or scotopic conditions. In spite of the severe cone-ERG deficits, visual acuity was only slightly reduced. We propose that the defect, which interferes marginally with the neuronal flow of information, lies in the structures responsible for the building of the b-wave.

Monocular contribution to the peak time of the binocular pattern visual evoked potential

The contribution of each monocular pathway to the timing of the binocular pattern visual evoked potential was assessed in situations where a significant interocular timing discrepancy was observed. Monocular and binocular pattern visual evoked potentials to 0.5 degree checks were recorded from normal subjects, normal subjects in whom one eye was blurred, patients with monocular amblyopia, and patients with resolved unilateral optic neuritis. Normal subjects showed facilitation, while suppression was evidenced in subjects with monocular blurring. In patients with amblyopia, the affected pathway had no effect on binocular pattern visual evoked potential latency, suggesting that the amblyopic eye was suppressed. In contrast, all patients with optic neuritis showed binocular averaging. Our results show that different forms of binocular interaction are evidenced in normal subjects, in amblyopia and in optic neuritis, and suggest that a comparative analysis of monocular and binocular pattern visual evoked potential peak times brings valuable information to the clinical evaluation that could be used to distinguish disease processes further.

Duchenne muscular dystrophy: negative scotopic bright-flash electroretinogram but not congenital stationary night blindness

Patients with Duchenne muscular dystrophy (DMD) have recently been reported to have an abnormal scotopic electroretinogram (ERG) showing weak rod-related responses along with a negative configuration of the bright-flash response, which has been described as being similar to the one in congenital stationary night blindness (CSNB). We compared qualitatively and quantitatively the ERGs of 6 subjects with DMD, 10 subjects with the complete form of CSNB (cCSNB), 13 subjects with the incomplete form of CSNB (iCSNB) and 1 subject with complex glycerol kinase deficiency (CGKD). The rod-related activity and the bright-flash responses were abnormal and similar in all four groups. The cone-related activity, however, was within normal limits only in the DMD group; the b-wave was subnormal in CGKD, truncated in cCSNB and nearly absent in iCSNB. The electrophysiologic signature in DMD clearly distinguishes the retinal function of these patients from any other retinal condition so far described.

Duchenne muscular dystrophy: negative scotopic bright-flash electroretinogram and normal dark adaptation

Recent reports indicate that most subjects with Duchenne muscular dystrophy (DMD) have a negative scotopic bright-flash electroretinogram (ERG). We performed dark adaptometry in seven patients with the DMD phenotype. Three patients had the negative bright-flash response combined with severely reduced rod-related activity; their mean psychophysical dark-adapted threshold was -5.5 +/- 0.3 (normally -5.4 +/- 0.3) cd.m-2. Two of the three patients were able to sit through the complete test: the profile of their dark adaptation curve was normal. The four other patients had a normal scotopic ERG, and their mean psychophysical dark-adapted threshold was -5.3 +/- 0.3 cd.m-2. One of the four was able to complete the entire procedure, and a normal profile was found. In patients with DMD the dark adaptation measurements are normal despite abnormalities in rod-related ERG activity.

Correlation between electroretinogram findings and molecular analysis in the Duchenne muscular dystrophy phenotype

Fifteen consecutive patients with the Duchenne muscular dystrophy (DMD) phenotype were studied. Each patient was asked to undergo an ophthalmic examination, an electroretinogram (ERG), and to donate a blood sample for molecular diagnosis. All 15 patients had a normal ophthalmic examination. Electroretinography was successful in 14/15 patients. The ERG tracings were normal in seven patients, abnormal in seven, and unreliable in one. Blood for molecular analysis was obtained in 12/15 patients. In the seven patients with a normal ERG, five underwent molecular analysis, and in these five no deletion was detected in the dystrophin gene. In the seven patients with an abnormal ERG, six had molecular analysis available, and all six were found to have a deletion. These results suggest that patients with a classic DMD phenotype are genetically heterogeneous, and that this heterogeneity is reflected in the ERG.

Negative-configuration electroretinogram in Oregon eye disease. Consistent phenotype in Xp21 deletion syndrome

OBJECTIVE

To determine whether abnormal configurations on electroretinogram were a consistent finding in patients with Xp21 deletion and to characterize the associated ophthalmologic phenotype.

DESIGN

Case series.

SETTING

University hospitals and eye institutes.

PATIENTS

Five patients with complex glycerol kinase deficiency (Duchenne-type or Becker's muscular dystrophy, glycerol kinase deficiency, and congenital adrenal hypoplasia) and demonstrated chromosomal deletions at Xp21. Control patients were matched by age.

MAIN OUTCOME MEASURES

Clinical information was obtained from medical records. Complete ophthalmologic examinations were performed. Electroretinography was performed using a Ganzfeld technique and chloral hydrate sedation.

RESULTS

We report the clinical features and abnormal configurations on electroretinograms of five patients with complex glycerol kinase deficiency, including follow-up studies on a previously described patient. The original patient had ocular hypopigmentation; four, strabismus; two, myopia; three, astigmatism; and one, symptomatic night blindness. All had negative configurations on scotopic electroretinograms showing a reduced-amplitude B wave in the dark-adapted state.

CONCLUSIONS

Our original report suggested a diagnosis of Aland Island eye disease, which appears to be an incomplete form of congenital stationary night blindness. Linkage data place Aland Island eye disease and congenital stationary night blindness at Xp11, whereas our patients had deletions at Xp21. The phenotype reported here may represent the effects of a single gene defect or the compound effects of the Xp21 contiguous gene syndrome (complex glycerol kinase deficiency). The phenotype is referred to as Oregon eye disease.

Longitudinal study of the early electroretinographic changes in Alström's syndrome

We obtained serial electroretinograms in four patients aged between 6 months and 5 years with Alström's syndrome and studied the early stages of the severe retinopathy that is characteristic of that disease. The weak electroretinographic signals found at age 6 months demonstrate a severe early cone dysfunction; one year later the cone activity is undetectable. The rod component of the electroretinogram is initially normal but can rapidly deteriorate to become undetectable as early as 5 years of age. These unusual electroretinographic findings are pathognomonic of Alström's syndrome and different from other cone-rod dystrophies or other syndromes with similar phenotypes such as Bardet-Biedl, Laurence-Moon, and Cohen syndromes.

Distinct electroretinographic oscillatory potential generators as revealed by field distribution

Oscillatory potentials (OPs) of the electroretinographic signal were recorded in five healthy subjects by means of dermal electrodes located at various positions along the infraorbital ridge and referred to either a frontal or a temporal electrode. Flashes of light were generated in a Ganzfeld stimulator, and OPs were recorded with the subjects' eyes in abduction and adduction. This arrangement of eyeball and electrode positions makes it possible to record the retinal activity from various axes; from a pupillary-posterior pole (longitudinal) axis to an equatorial axis. The individual OPs were found to be selectively affected by the axis of recording, thus suggesting distinct sources of generation. All the OPs reversed in polarity as the recording axis maintained by the electrodes was moved from the longitudinal to the transverse axis. The point of inversion of OP2 and OP3 was similar, as was their amplitude ratio (OP3/OP2), which remained independent of the eye position. However, OP4 became inverted at a different location, closer to the longitudinal axis, and the amplitude ratio (OP4/OP2) varied significantly with the eye position. Altogether, these results suggest different retinal source generators for OP2 and OP3, and for OP4.

Autosomal recessive cerebellar hypoplasia and tapeto-retinal degeneration: a new syndrome

Two sisters with autosomal recessive cerebellar hypoplasia and severe nonprogressive retinal pigmentary disease are presented. This syndrome has been previously described in only 1 patient. The retinal changes may be difficult to discern and we suggest that all patients with congenital ataxia have a detailed ophthalmologic assessment, including electroretinography.