Relationship between [123 I]-FP-CIT SPECT and clinical progression in Parkinson's disease

BACKGROUND

The demonstration of presynaptic dopaminergic deficiency on [¹²³ I]-FP-CIT SPECT imaging is a useful ancillary tool in the diagnosis of Parkinson's disease (PD). Whilst there is evidence of a cross-sectional relationship between the degree of dopaminergic deficiency and severity of bradykinesia and rigidity, longitudinal studies are rare. Moreover, the relationship between motor subtypes and their dopaminergic deficient state is not well characterized.

AIM

Our primary aim was to assess the correlations between dopaminergic deficiency on baseline [¹²³ I]-FP-CIT SPECT imaging with the progression of motor severity in patients classified by motor subtype, and the development of motor complications. Our secondary aim was to assess the correlation between UPDRS-III subscores and the time to onset of motor complications.

METHODS

42 PD patients with abnormal baseline [¹²³ I]-FP-CIT SPECT scans and at least 3 years of clinical follow-up were classified by motor subtype: akinetic-rigid, tremor-dominant or mixed. UPDRS-III scores at baseline and at 3-year follow-up, and time to onset of motor complications were recorded.

RESULTS

[¹²³ I]-FP-CIT uptake ratios were inversely correlated with UPDRS-III scores at 3 years only in akinetic-rigid patients (r=-.51, P=.04). Time to onset of motor complications was inversely correlated with UPDRS-III subscores for bradykinesia and rigidity at baseline (r=-.52, P=.02) and at 3 years (r=-.54, P=.01).

CONCLUSION

The degree of dopaminergic deficiency on baseline [¹²³ I]-FP-CIT SPECT inversely correlates with motor severity at 3-year follow-up in akinetic-rigid patients only. Furthermore, UPDRS-III subscores for bradykinesia and rigidity at baseline show an inverse correlation with time to onset of motor complications across all PD subtypes.

Methodological quality, completeness of reporting and use of systematic reviews as evidence in clinical practice guidelines for paediatric overweight and obesity

Paediatric obesity rates remain high despite extensive efforts to prevent and treat obesity in children. We investigated the quality of the methodology and reporting within systematic reviews (SRs) underpinning paediatric content in US clinical practice guidelines (CPGs). In June 2016 we searched guideline clearinghouses and professional organization websites for guidelines published by national or professional organizations in the United States from January 2007 onwards. In our primary, a priori analysis, we used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) instruments to score SRs and meta-analyses that included paediatric populations and were cited by included CPGs. In a secondary, post hoc analysis, we determined the extent to which US CPGs use available, relevant SRs and meta-analyses compared with non-US CPGs. Eight US-based CPGs with 27 references to 22 unique SRs were found. AMSTAR and PRISMA scores were low overall, with only three SRs having 'high' methodological quality. Items dealing with bias assessments and search strategies had especially low scores. US CPGs were also older on average and cited fewer SRs than their international counterparts. Low quality scores and dated guidelines should be a cause for concern among practicing clinicians and a call to action for future guideline developers, publishers and research institutions.

Baseline [(123) I]FP-CIT SPECT (DaTSCAN) severity correlates with medication use at 3 years in Parkinson's disease

BACKGROUND

Presynaptic dopaminergic deficiency on dopamine transporter imaging supports a clinical diagnosis of Parkinson's disease and correlates with the severity of rigidity and bradykinesia. Baseline dopaminergic deficiency predicts clinical severity, but the relationship with subsequent medication use has not been reported.

METHODS

A randomly selected cross section of 83 Parkinson's disease (PD) patients who had [(123) I] FP-CIT SPECT at the time of clinical diagnosis was identified. Dopaminergic deficiency was graded 1, 2 or 3 with increasing severity using visual assessment and by semiquantitative analysis of putamen and caudate uptake. Antiparkinson medication usage and clinical severity by Hoehn and Yahr were noted annually to 3 years.

RESULTS

In 83 patients (66% male, median age 65.0 years, IQ 55.4-71.8), [(123) I]FP-CIT SPECT was grade 1 in 20 (24%), grade 2 in 53 (64%) and grade 3 in 10 patients (12%). Dopamine transporter uptake ratios were inversely associated with antiparkinson medication usage (r = -0.26, P = 0.0201) and Hoehn Yahr stage (r = -0.32, P = 0.0029) at 3 years from baseline, but there was considerable variation in drug usage in individual patients. At 3 years, patients with grade 1 scans at baseline received a median dose of 325 levodopa equivalent units (LEU) (interquartile range 175-433); grade 2 scan patients 400 LEU (interquartile range 300-635); and grade 3 scan patients 460 LEU (interquartile range 252-658).

CONCLUSION

The degree of reduction in presynaptic dopaminergic uptake at baseline is associated with higher antiparkinson drug dosage at follow-up, but the wide variation means that the baseline FP-CIT SPECT does not reliably predict drug use in individual cases.

Duration of L-dopa and dopamine agonist monotherapy in Parkinson's disease

The expected duration of initial antiparkinson monotherapy before the need for supplementation is not clearly defined for routine practice. The aim of this study was to define the length of L-dopa (L-3, 4-dihydrophenylalanine) and dopamine agonist monotherapy. The duration of monotherapy and discontinuation rates were investigated in a natural observational setting by plotting Kaplan-Meier survival curves. Out of 345 patients, 180 (52.2%) received L-dopa and 165 (47.8%) received a dopamine agonist as initial monotherapy. Half of the patients starting L-dopa received supplementary therapy with- in 3.6 years (95% confidence interval, 3.2-4.6), significantly longer than for dopamine agonist monotherapy (half required a second agent at 2.3 years [2.0-2.9]; P = 0.00017). Discontinuation of L-dopa therapy was 1%. Dopamine agonists were stopped (due to side-effects like impulse control disorders [6%], somnolence [4%] and light-headedness [3%]) in 20% over four years. The duration and tolerability of L-dopa and dopamine agonists as initial Parkinson's disease monotherapy are defined in this study; this may form part of the information exchange with patients.

Instrumente zur Diagnostik der Aufmerksamkeitsdefizit-/Hyperaktivit�tsst�rung (ADHS) im Erwachsenenalter

We report on the development of a German self-rating behaviour questionnaire (ADHD-SR) and diagnostic checklist (ADHD-DC) for the diagnosis of attention-deficit/hyperactivity disorder in adults according to DSM IV and ICD 10 research criteria. When comparing self-rating with expert rating, we found good concordance measured by intraclass coefficients on the level of single symptoms and syndrome scores. High retest reliability of the ADHD-SR demonstrated the ability to assess time-stable behaviour traits. Evaluation of the psychometric properties revealed good internal consistency and adequate convergent and divergent validity measured by the "big five" derived from the NEO-FFI and the constructs impulsivity, venturesomeness, and empathy of Eysenck's impulsiveness questionnaire. We detected a remarkable correlation with the Wender Utah Rating Scale, which targets the detection of childhood ADHD symptoms. Diagnostic sensitivity for different cutoff points was calculated by ROC analysis at 65--88%. Specificity was 67% to 92%.

[Drug therapy of patients with emotionally unstable personality]

BACKGROUND

Most patients with borderline personality disorders are treated with psychotropic medication. There are, however, no clear clinical guidelines concerning optimal treatment of the disorder.

MATERIAL AND METHODS

This article reviews the data on the efficacy of treatment with different classes of psychopharmacological drugs. The emphasis is on clinical trials published after 1981, as most placebo-controlled double-blind studies have been done in the last two decades. Furthermore, studies conducted before 1980 are more difficult to interpret because of changes in clinical diagnostic criteria.

RESULTS

Neuroleptics have been studied most extensively followed by antidepressants. Neuroleptics have a modest, but broad therapeutic effect on symptoms in all domains. Doses are lower than those used for treating schizophrenia. Antidepressants have a more inconsistent effect. Tricyclics have been the least successful, whereas irreversible MAO inhibitors and selective serotonin reuptake inhibitors (SSRIs) have been effective in treating mood symptoms and impulsivity. Lithium has a possible effect in diminishing anger and suicidal symptoms.

INTERPRETATION

As there is no "drug of choice" for the treatment of borderline personality disorder, a more rational clinical approach might be to treat different symptom clusters (cognitive/schizotypal, affective, impulsive) rather than the disorder itself. Finally, some practical guidelines for drug treatment of the disorder are proposed.

Matrix metalloproteinases and collagen ultrastructure in moderate myocardial ischemia and reperfusion in vivo

Severe ischemic injury or infarction of myocardium may cause activation of matrix metalloproteinases (MMPs) and damage the interstitial matrix. However, it is unknown whether MMP activation and matrix damage occur after moderate ischemia and reperfusion that result in myocardial stunning without infarction, and if so whether such changes contribute to postischemic myocardial expansion and contractile dysfunction. To address these questions, open-chest anesthetized pigs underwent 90 min of regional ischemia (subendocardial blood flow 0.4 +/- 0.1 ml. g(-1). min(-1)) and 90 min of reperfusion. After ischemia plus reperfusion, histological and ultrastructural examination revealed no myocardial infarction or inflammatory cell infiltration. Myocardial MMP-9 content increased threefold with a fourfold increase in the active form (P < 0.001). Myocardial collagenase content doubled (P < 0.01) but remained in latent form. MMP-2 and tissue inhibitors of metalloproteinases were unaffected. Despite increases in MMPs, collagen ultrastructure (assessed by cell maceration scanning electron microscopy) was unaltered. Intracoronary administration of the MMP inhibitor GM-2487 did not prevent or attenuate myocardial expansion (assessed by regional diastolic dimensions at near-zero left ventricular pressure) or contractile dysfunction. We conclude that although moderate ischemia and reperfusion alter myocardial MMP content and activity, these effects do not result in damage to interstitial collagen, nor do they contribute to myocardial expansion or contractile dysfunction.

Aortic vasculopathy with aneurysm: a rare cause of fetal hydrops

An hydropic fetus seen at 28-weeks gestation had a saccular aortic aneurysm in the descending thoracic aorta. Histology disclosed marked fibrointimal hyperplasia, thrombus, and attenuation of the tunica media. The remainder of the descending thoracic aorta showed fibrointimal hyperplasia. We speculate that the narrowed lumen and rigid aortic wall resulting from this vasculopathy provided an increased afterload leading to cardiac failure.

Successfully solo

Each day, between office visits and rounds at Methodist Hospital, oncologist Gail Bender sees anywhere from 17 to 30 patients. She does this five days a week, working from 7 a.m. to 4 p.m., and she spends about three hours Saturday and Sunday seeing patients in the hospital and finishing paperwork. She's always keeping a close eye on expenses, and, like most physicians, she's spending considerable time dealing with payers. Unlike most of her colleagues, she's in business for herself.

[Supraventricular tachycardia treated with percutaneous catheter ablation of the arteriovenous conduction system]

Twelve patients with supraventricular tachycardia refractory to medical management were treated with catheter ablation (fulguration) of the atrioventricular (AV) conduction system followed by pacemaker implantation. All 12 patients had initially 3 degrees AV block. In ten patients it was permanent. One patient had a permanent 1 degree AV block and left bundle branch block. In one patient with initial 3 degrees AV block AV conduction resumed. No major complications were seen. At follow-up, the mean observation period was 15 months (range 3-57 months). All ten patients with permanent 3 degrees AV block were free of arrhythmic symptoms and without any medication. The patient with permanent 1 degree AV block was free of symptoms and arrhythmia, but died 16 months after the ablation. The patient with relapse of the AV conduction continued to have arrhythmic symptoms, but ECG did not confirm arrhythmia. It is concluded that catheter induced 3 degrees AV block is a safe and efficient treatment of patients with supraventricular tachycardia refractory to medical treatment.

[Dementia evaluated by means of a mini-mental status examination. Clinical neurologic patient material]

The mini-mental state examination (MMSE) was administered to a neurological patient material with various disorders. The test was found useful for detecting cognitive impairment. The test did not differentiate reliably between different causes of cognitive impairment. To detect dementia a cut-off score of 25 or less yielded 100% sensitivity and 97% specificity. The validity of the DSM-III-diagnostic criteria for dementia, primary degenerative dementia and multi-infarct dementia was high. The modified ischemic score (MIS) seemed to be of limited value in differentiating primary degenerative dementia from multi-infarct dementia.

Parasuicidal snow-wandering in Arctic northern Norway

Psychiatric morbidity in the Arctic has not been extensively studied. Seasonal variations in climate, light and darkness are unique for these areas and impose special kinds of strains on the population. Three case-histories focusing on snow-wandering as a parasuicidal act are presented. One of them bears some resemblance to the Arctic hysteria described among Eskimoes. Reasons for choosing snow-wandering as an alternative to other kinds of suicide are discussed and a hypothesis is suggested. The psychological and physiological factors as explanations for post snow-wandering amnesia are discussed.

Sleep apnoea and organic solvent exposure

Fifteen patients referred for the evaluation of possible organic solvent encephalopathy were studied by clinical polysomnography. Seven had more than 30 apnoeas per night and an apnoea index of higher than 5, thus fulfilling the commonly used criteria of the sleep apnoea syndrome. Another group of eight workers exposed to trichlorethane, examined without prior knowledge of their individual symptoms, showed a significantly elevated number of sleep apnoeas compared with nine controls. The results indicate that organic solvent exposure can cause sleep apnoea.

Continuous registration of cardiac output with a new computer system designed for hot-film anemometry: an in vitro study

We have developed and improved a method for the continuous on-line registration of cardiac output. By measuring blood velocity with a hot-film anemometer probe in the pulmonary artery, cardiac output can be estimated by gated systolic integration of the velocity signals. The integrated value for a certain period can be converted to a cardiac output proportional value. A thermistor placed next to the velocity probe enables thermodilution measurement of cardiac output, which serves as in vivo and in situ calibration. In this paper an in vitro study of the method applied to pulsatile flow is presented. A good correlation was found between real flow and both the velocity method and the thermodilution method. Fluid temperature and changing stroke volume and/or pulse frequency had minimal influence on accuracy, whereas altered probe position required recalibration for the velocity method but not for the thermodilution method. The advantages of the velocity method for the measurement of cardiac output are: The continuous on-line monitoring of cardiac output. The need for the injection of only very small volumes of cold saline, as the frequency of thermodilution measurements is reduced.

[Clinical aspects and course of Sturge-Weber syndrome in childhood]

We report on symptoms, clinical course and prognostic factors of eight children (6 girls and 2 boys) with Sturge-Weber syndrome. The period of observation was 1 to 17 years (mean 8.8 years). All patients had the classical symptoms with facial port-wine stain nevus and intracranial calcifications. In two cases a bilateral distribution of the nevus was found. All patients but one had epileptic seizures which were followed by Todd's palsies in five. Four children additionally suffered from hydrophthalmia. Another patient had an angiomatosis of the retina and cataract. Neurological findings were normal in three patients, minimal signs were found in three, one patient had a spastic hemiplegia and another one hypotone tetraplegia. The mental development was normal in three patients, however severe dyscalculia occurred in one of them. Five patients were mentally retarded, three of them severely. The prognosis was the worse the earlier the cerebral seizures appeared.

A device for treatment of destrusor hyperreflexia by bio-feedback

Treatment of detrusor hyperreflexia is still a difficult field. Recently bio-feedback has been described as a successful treatment of voiding dysfunction. In this paper we describe a device, which makes it possible for the patients to register any pressure changes in the bladder.

Peristalsis of the pyeloureter in pigs measured by videodensitometry

The peristaltic activity of the upper urinary tract was investigated by means of a simple videodensitometric system. Through a transparenchymally placed catheter contrast medium was infused into the renal pelvis with perfusion rates increasing from 1 to 15 ml/min. Sequences of 3-5 min were recorded by means of a Siemens image amplifier on videotape for later analysis. Photodiodes were placed on the screen over the calyces, renal pelvis and ureter at a distance of 5 cm. An amplifying system and a UV recorder were used for registration. Peristaltic frequency, transmission velocity and average bolus volume were measurable in 8 out of 10 pyeloureteral units. Additionally, calyceal activity was detectable in one case. The tracings obtained by videodensitometry were reproducible and easy to analyse. Conversion of videorecordings to analogue signals for analysis might be a possible future clinical diagnostic method.

Topographic variations in alpha-adrenergic and cholinergic response in the pig renal pelvis

The effect of alpha-adrenergic and cholinergic receptor stimulation is quantitatively analyzed in different regions of the pig pyeloureter. Smooth muscle strips from minor calyces, pelvis proper and ureter were investigated. Stimulation with potassium (127 mM) was used as reference. Both phenylephrine and carbachol caused a concentration-dependent increase in basal tone in the pelvis and the minor calyx. The maximum response obtained was significantly smaller in the pelvis than in the minor calyx. As compared to phenylephrine, the response to carbachol was negligible. The ureter showed a different behavior as compared to the minor calyx and pelvis. A constant basal tone could not be obtained and the tissue did not respond to potassium in a reproducible way.

A water-insensitive ventilator alarm

Most of the low-pressure ventilator alarms available have the pressure registration unit connected to the patient circuit by a narrow bore plastic tube. Condensed water in this tube will stop the correct function of the alarm in a few hours if the tube is placed after a heated humidifier. The pressure registration should be as close to the patient's tracheal tube as possible to monitor the pressure of the airway and hence a ventilator alarm with the pressure sensing unit in the patient circuit is described. The alarm has proved to be reliable, insensitive to water and very easy to adjust to maximum sensitivity.

Temperature alarm for heated humidifiers

In order to ensure a water content of between 30 and 40 mg/l in the inspiratory gases using a heated humidifier, the temperature in the delivery tube, near to the patient, must be between 30 and 37 degrees C. A low cost thermistor temperature alarm is described which indicates by means of different coloured lights if the temperature falls below 30 degrees C, lies between 30 and 37 degrees C, or if the temperature exceeds 37 degrees C. An alarm also sounds if temperatures above 37 degrees C occur. This device has been in use since 1974 and has proved reliable and time saving.