30 Informant-Reported Decline Associates with Silent Acute Stroke Lesions and Worse Small Vessel Disease in Mild Stroke Patients

Introduction

Small vessel disease (SVD) commonly causes stroke and dementia. Early clinical predictors of disease progression are lacking. We aimed to determine whether informant reports of chronic cognitive/functional decline, prerequisites for dementia diagnosis, are associated with (a)baseline SVD burden, measured by Fazekas scores and (b)SVD change, measured by incident subcortical Diffusion-weighted Imaging (DWI) lesions.

Method

We prospectively recruited patients with mild ischaemic stroke, performed diagnostic MRI, and invited participants to repeat MRI 3- to 6-monthly. Informants completed the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) prior to baseline visit, a 16-item questionnaire which assesses patients’ cognitive and functional decline in the preceding ten years. Scores range from 1–5: a score above 3.3 has high sensitivity/specificity for dementia post-stroke. We conducted linear regression with IQCODE as the dependent variable, adjusting for age, sex, baseline MoCA, disability (modified Rankin Scale).

Results

We recruited 106 participants (mean age 67 years;range 40–86;33% female). Ninety-three informant questionnaires were returned. IQCODE associated with baseline Fazekas score; Fazekas 6 (β = 0.28, p = 0.04) vs. Fazekas 3 (β = 0.03, p = 0.67), R2 = 0.11, adjusted for age, sex, baseline MoCA, disability.

Incident DWI lesions were common (15/106; 14/15 subcortical; no active embolic sources; median 67 days post-stroke). Four were asymptomatic, two reported stroke-like symptoms and nine had neuropsychiatric/non-focal symptoms. IQCODE was higher in those with a new lesion vs. without (β = 0.21, p = 0.02), R2 = 0.09, while age (β = −0.004, p = 0.19), MoCA (β = −0.006, p = 0.56) and disability (β = 0.06, p = 0.2) were not.

Conclusions

Higher SVD burden and incident, mostly “silent” stroke lesions associate more strongly with informant concerns of cognitive/functional decline than age or objective cognitive tests. These findings are novel in an ischaemic stroke population and the first to assess IQCODE/SVD progression. Future work should determine whether combining informant reports with imaging features of small vessel disease improves early detection of dementia.

Experimental validation of a novel compact focusing scheme for future energy-frontier linear lepton colliders

A novel scheme for the focusing of high-energy leptons in future linear colliders was proposed in 2001 [P. Raimondi and A. Seryi, Phys. Rev. Lett. 86, 3779 (2001)]. This scheme has many advantageous properties over previously studied focusing schemes, including being significantly shorter for a given energy and having a significantly better energy bandwidth. Experimental results from the ATF2 accelerator at KEK are presented that validate the operating principle of such a scheme by demonstrating the demagnification of a 1.3 GeV electron beam down to below 65 nm in height using an energy-scaled version of the compact focusing optics designed for the ILC collider.

A cultural-contextual perspective on the validity of the MMPI-2 with American Indians

This study investigated the normative validity of the MMPI-2 with two distinct American Indian tribes. Differences occurred on 8 of the 13 basic validity and clinical scales (F, 1, 4, 5, 6, 7, 8, 9) between the MMPI-2 norms and both tribal samples. Elevated MMPI-2 scores of American Indians may not only reflect the possibility of psychological distress spurred by historical oppression and present adversity, but also an expression of a divergent worldview. Considering the context of the historical and social production of knowledge about American Indians, it is argued that researchers and practitioners, when interpreting MMPI-2 results for American Indians, should seriously consider their interpretive points of reference, which may be impacted by dominant cultural belief systems.

In vivo determination of optical properties of normal and tumor tissue with white light reflectance and an empirical light transport model during endoscopy

Determination of tissue optical properties is fundamental for application of light in either therapeutical or diagnostics procedures. In the present work we implemented a spatially resolved steady-state diffuse reflectance method where only two fibers (one source and one detector) spaced 2.5 mm apart are used for the determination of the optical properties. The method relies on the spectral characteristics of the tissue chromophores (water, dry tissue, and blood) and the assumption of a simple wavelength dependent expression for the determination of the reduced scattering coefficient. Because of the probe dimensions the method is suited for endoscopic measurements. The method was validated against more traditional models, such as the diffusion theory combined with adding doubling for in vitro measurements of bovine muscle. Mean and standard deviation of the absorption coefficient and the reduced scattering coefficient at 630 nm for normal mucosa were 0.87+/-0.22 cm(-1) and 7.8+/-2.3 cm(-1), respectively. Cancerous mucosa had values 1.87+/-1.10 cm(-1) and 8.4+/-2.3 cm(-1), respectively. These values are similar to data presented by other authors. Blood perfusion was the main variable accounting for differences in the absorption coefficient between the studied tissues.

Diet selection and productivity of sheep grazing contrasting pastures

A grazing experiment was conducted at the Big Ridge 2 site CSIRO, Chiswick (30˚31′S, 151˚39′E), 20 km south of Armidale, New South Wales, Australia. The site was established in 1955. In March 1966, phalaris and white clover were sown and pastures were fertilised annually with superphosphate until 1993. There were 3 pasture treatments, each with 2 replicates: degraded pasture (low phalaris content), phalaris-dominant, and phalaris–white clover. The effect of pasture type on animal production (liveweight gain and wool) was only significant in 1996, when there were large differences in pasture composition and production between the 3 pasture types. n-Alkane based estimates showed that pasture degradation affected diet selection and nutrient intake and thus sheep production. The estimates in this study also showed no clear preference for a single pasture species over time and lack of strong preferential selection for clovers when sheep were grazing 3 contrasting pastures. Preferential selection of a particular species varied over time depending on the presence and availability of alternative species. Although there were large differences in total N and S intake and faecal output between the 3 pastures, the proportion of the dietary nutrient used for production was similar. This observation reveals the importance of further improving pasture and grazing management, particularly in productive phalaris–white clover pasture with high nutrient flux, to improve nutrient recycling through plant uptake and retention by animals in the grazing ecosystem, and reduce losses.

The pathogenicity of Clostridium difficile

It is now well established that the major virulence factors of C. difficile are the two toxins A and B. However, the organism possesses an array of other putative virulence factors that may be important for localisation within the colon, and in evasion of the immune system. It has been observed that certain types of C. difficile are more commonly found causing disease than others, and this seems to be independent of toxin production. Is this simply a reflection of their abundance in the hospital environment, or is it due to their virulence determinants? This review covers our current knowledge of the modes of action of toxins A and B at the cellular and molecular level. Many unanswered questions are posed that require answers before we can fully understand the pathogenic mechanisms of the organism and be in a position to manage better the spectrum of diseases it causes.

Outcome of the prenatally diagnosed congenital cystic adenomatoid lung malformation: a Canadian experience

Congenital cystic adenomatoid malformation of the lung (CCAM) is diagnosed by prenatal ultrasonography with an increasing frequency but controversy persists as to its prognosis and prenatal management.

METHOD

A multi-institutional study of cases of CCAM diagnosed antenatally identified by ultrasonographers and by a review of hospital charts.

RESULTS

We obtained 48 cases from five centers. We estimate the incidence of CCAM at 1:25,000 to 1:35,000 pregnancies. The incidence of voluntary abortions was 15% (7/48), of spontaneous abortions 2% (1/41) and of postnatal death 10% (4/40). One of the postnatal deaths was from trisomy 18. Of the 7 aborted fetuses, 2 had multiple malformations and 1 had severe hydrops and oligohydramnios; the other 4 had a large mass with mediastinal displacement but without hydrops. When pregnancy was allowed to continue, 56% of the lesions regressed spontaneously, even though one third of these had initial progression. In 17 cases (42%) the mediastinal shift corrected itself, sometimes by simple growth of the fetus but most often by a decrease in the size of the lung mass. In 1 fetus, repeated needle decompressions followed by double-pigtail catheter drainage of large cysts allowed regression of hydrops. Despite this, neonatal death occurred from pulmonary hypoplasia.

CONCLUSION

CCAM can lead to fetal or neonatal demise from hydrops, lung hypoplasia, prematurity or severe associated malformations, but has a good prognosis in the majority of cases.

Successful chemotherapeutic decompression of primary endodermal sinus tumor presenting with severe spinal cord compression

Management of spinal cord compression from a primary paraspinal endodermal sinus tumor (EST) is described. A 17-month-old child presented for treatment with near-complete paraplegia secondary to spinal cord compression from a primary paraspinal EST. The child was treated with cisplatin-based chemotherapy without laminectomy or radiation therapy. Rapid resolution of symptoms was observed. The child had an excellent tumor response and complete neurologic recovery with no sequelae. Chemotherapy alone is an alternative to laminectomy or radiation therapy in the management of epidural cord compression from EST, even when the cord compression is severe.

A porcine model of gastroesophageal reflux

The exact mechanism by which the lower esophageal sphincter (LES) prevents gastroesophageal reflux disease (GERD) remains controversial. The two main reasons for this controversy are the lack of a good animal model and the only recent technologic advances in this field. To date, no animal models exist that use 24-hour pH studies, manometry, and endoscopy in evaluating GERD. The purpose of this study is to create a good model of GERD that uses this technology and to delineate the true nature of the LES more clearly. Recently, three-dimensional vector volume studies were performed and through detailed, cadaveric, anatomic studies, the vector volume profiles were correlated to distinct groups of muscle fibers at the gastroesophageal junction in humans. In this study, an anatomic analysis of the porcine gastroesophageal junction revealed an arrangement of muscle fibers similar to that in humans. A myectomy of the porcine oblique fibers was performed in nine piglets weighing 10 to 12 kg. The authors were able to demonstrate manometric attenuation of the porcine LES, gastroesophageal reflux by ambulatory 24-hour pH monitoring (P < 0.0025), and the creation of GERD by documenting esophagitis grossly and histologically. In conclusion, this model of GERD works and lends further support to the notion that the LES may be a discrete anatomic entity.

Nurse education: a time for new solutions?

Notes the worsening situation with regard to nursing shortages. Considers responses such as the commission of increased places on Project 2000 courses and the introduction of NVQ III staff. Points to this success, particularly with regard to the latter of these solutions, but notes a lack of career progression for such entrants. Suggests that there is a strong case for development of a better career path for NVQ III staff, and looks to education and training consortia in this respect.

Delivering comprehensive services to homeless mentally ill offenders

A consortium of social services agencies developed a comprehensive community mental health services program for homeless mentally ill offenders in Portland, Oregon. Residential services were provided in a single-room-occupancy hotel. Forty-seven clients were accepted for the program, 38 actually entered the program, and 14 graduated--that is, attained sobriety and were placed in community housing. Problems complicating program implementation included differing philosophical approaches of key agencies, staff turnover, and financial shortfalls. Many potential clients were not accepted into the program because of recent violence or potential violence; some clients were expelled or reincarcerated because of violent behavior.

Long-term continuous ambulatory peritoneal dialysis in diabetics

Of 147 diabetic patients with end-stage renal disease who were treated in our CAPD program between 1978 and 1991, 6 men and 1 woman (5 had type II and 2 type I diabetes) with a mean age of 54 (range 21-70) years have been on CAPD for more than five years (mean: 76 mos, range: 65-109 mos) and on peritoneal dialysis (IPD+CAPD) for an average of 85 (range: 67-118) mos. They had a variety of comorbid conditions at the start of CAPD: Retinopathy (5/7), blindness (3/7), hypertension (5/7), peripheral neuropathy (7/7), peripheral vascular disease (3/7), congestive heart failure (3/7), myocardial infarction (1/7), ischemic heart disease (2/7). Two were smokers and five over the age of 65. Peritonitis rate was 1 episode/11.4 pt mos, exit-site infection 1/76.4 pt mos and average hospitalization rate 32.8 days/patient/year. Hypertension was well-controlled with discontinuation of all medications; after initiation of CAPD two of them remained without medications throughout the study but in the rest, medications had to be restarted. As assessed by HbA1c, blood glucose control improved with IP administration of insulin. Residual renal function progressively decreased. None of them developed severe hyperparathyroidism. Peripheral neuropathy remained stable in four and deteriorated in two. Total protein, albumin, cholesterol and triglycerides decreased during the last two years indicating a degree of malnutrition. Our experience with these seven patients suggests that diabetic patients, even the aged and those with many comorbid conditions and complications, can survive for long periods on CAPD.

Interpretation of soil tests: a review

Soil tests tell how much nutrient is extractable, some of which may be present in a plant-available form, and/or the amount that may become available to the crop or pasture. This is a quantitative measure of nutrients. Interpretation depends on the skill of interpreters, and a major factor in interpretation is experience. Accurate interpretation is only possible when the sample collected from the field is representative of the site, and this can best be achieved using monitor plots rather than the traditional zig-zag method of sampling. One of the main deficiencies in experimental data used to interpret soil tests is the poor characterisation of experimental sites and of the climatic conditions during the experiment. Better characterisation would allow better interpretations to be made. With the development of equipment that is able to analyse multiple elements (e.g. ICP-AES), investigation of multiple extractants should be expanded in Australia. Of these, the Mehlich No. 3 and AB-DTPA extractants would seem the most appropriate. Because of the frequent relocation of agriculture advisers, experience is often lost; hence, there is a need for GIS/Expert systems to gather this experience. The development of such systems will allow new personnel to understand more rapidly the characteristics of soils, climate, and crops in an area. The final decision on fertiliser rates depends on the financial situation of the farmer. Soil testing and interpretation of these results is just 1 factor used to make the fertiliser decision.

Inflammatory pseudotumors in children

Inflammatory pseudotumors are so named because they mimic malignant tumors clinically and radiologically. Most often seen in the lungs of young adults, they consist of localized proliferations of mononuclear inflammatory cells and myofibroblasts. There are scattered reports of these tumors occurring in various sites in children. We report five cases of these rare lesions in children; four arising intraabdominally and one in the lung. In contrast to the usual presentation in adulthood, these children were all previously healthy. One child, with the tumor arising from the urinary bladder, was originally diagnosed as having a malignant sarcoma and underwent pelvic exenteration and chemotherapy for this subsequently-proven benign lesion. Local recurrence occurred in one case. Total excision is indicated and is usually possible without unacceptable morbidity. Our cases and a review of the literature point out the importance of pathologic differentiation of these lesions from malignancy with early appropriate surgery.

Chronic intussusception due to antral myoepithelioma

Intussusception was seen on abdominal sonography and computed tomography in a 15-year-old boy who presented with a 6-week history of weight loss, vomiting, abdominal pain, abdominal mass, and hyperamylasemia. Laparotomy revealed a chronic gastroduodenal intussusception, the lead point of which was an antral myoepithelioma, a rare entity in this age group.

Cross-cultural aspects of sleep in the elderly

A sleep questionnaire (SQ) was administered to 850 adults, 50 years and older, drawn from urban areas in 7 countries (Australia, Greece, Italy, Mexico, Spain, Venezuela, United States). All were functioning adults in relatively good physical and mental health. The samples were equated on sex, age, and occupational level. Of the 8 scales on the SQ, 7 showed statistically significant differences between countries, and 3 between males and females. At the same time, substantial similarities were found and are discussed from a normative point of view.

Angiographic demonstration of an aorto-left renal vein fistula

The unusual complication of an atherosclerotic abdominal aneurysm rupturing into a retro-aortic left renal vein is presented. Angiographic findings and the anatomic variations of the left renal vein are discussed.

Subjective assessment of sleep by Sleep Questionnaire

A 55-item Sleep Questionnaire is presented for possible use as a standardized instrument in psychological studies of sleep. A factor analysis of responses from 145 adults to the questionnaire indicated 7 factors accounted for 71.7% of the total variance. These factors are congruent with sleep dimensions discussed in the literature and with other factor analytic investigations. A set of 11 clinical judgment scales are also presented. The reliabilities of both factor and clinical scales are adequate as judged by test-retest, internal consistency, and comparisons of self vs spouse ratings. The construct validity is supported by three studies showing significant differences between (a) medical patients with and without sleep disturbances, (b) psychiatric patients with and without symptoms of depression, and (c) short and long sleepers.

Blunt splenic trauma: diagnosis and management

To examine the morbidity and mortality associated with blunt splenic injuries, the authors reviewed the results in 106 such patients treated in the Sunnybrook Regional Trauma Unit between June 1, 1976 and June 30, 1983. Initial assessment included peritoneal lavage in 86 patients. No patient with known or suspected splenic injury was treated nonoperatively nor were any patients found to have had splenic injuries missed at the initial assessment. Seventy-one splenectomies and 35 splenorrhaphies were performed. The overall mortality was 25% and 10 surviving patients had serious complications. The splenic injury itself was never the cause of death. Only one patient who initially underwent splenorrhaphy later required splenectomy. It is concluded that blunt splenic injury is rarely the cause of death or serious morbidity when a policy of immediate diagnosis and operative treatment is carried out. Furthermore, in selected patients, splenorrhaphy is a safe and effective treatment.

Continuous ambulatory peritoneal dialysis in diabetics with end-stage renal disease

Twenty diabetics with end-stage renal disease who had never previously received dialysis treatment were treated with continuous ambulatory peritoneal dialysis for periods of two to 36 months (average, 14.5). Intraperitoneal administration of insulin achieved good control of blood sugar. Even though creatinine clearance decreased significantly (P = 0.001), control of blood urea nitrogen and serum creatinine was adequate. Hemoglobin and serum albumin levels increased significantly (P = 0.005 and 0.04, respectively). Similarly, there was a significant increase in serum triglycerides and alkaline phosphatase (P = 0.02 and 0.05). Blood pressure became normal without medications in all but one of the patients. Retinopathy, neuropathy, and osteodystrophy remained unchanged. Peritonitis developed once in every 20.6 patient-months--a rate similar to that observed in nondiabetics. The calculated survival rate was 93 per cent at one year; the calculated rate of continuation on ambulatory peritoneal dialysis was 87 per cent. We conclude that continuous ambulatory dialysis with intraperitoneal administration of insulin is a good alternative treatment for diabetics with end-stage renal disease.

Functional evaluation of the porcine heterograft in the mitral position

In vivo function of glutaraldehyde-fixed porcine heterografts used for mitral valve replacement was evaluated by cardiac catheterization in 14 of our first 33 patients who have undergone mitral valve replacement with this prosthesis. Diastolic gradients were present in each patient. Average mean diastolic gradient was 6.5 mm Hg for the group, and average end-diastolic gradient was 3.0 mm Hg. Calculated mitral valve orifice areas ranged from 0.92 cm2 to 3.39 cm2, the average being 2.15 cm2. With rapid pacing (heart rate approximately 140), average mean gradient increased by 6 mm Hg. No patient had mitral regurgitation. Two patients had calculated mitral valve areas of 1 cm2 or less; one of these was found at postmortem examination to have thrombus adherent to the ventricular aspect of 2 of the 3 valve leaflets, rendering them immobile.