Small Intestinal Manometric Studies in Patients with Familial Visceral Myopathies

We studied jejunal manometry on 10 patients with type 1 familial visceral myopathy (FVM), and one patient each with types II and III. Two patients of type I and both patients of types II and III had intestinal pseudo-obstruction syndrome. The record was obtained in each patient for 4 to 5 hours during fasting, and 1 hour after feeding. In type I FVM, migrating motor complexes were present in six and absent in four patients. In these four patients (two with intestinal pseudo-obstruction syndrome) with absent migrating motor complexes, there was infrequent low-amplitude contractions during fasting, and after feeding. In six patients with migrating motor complexes, the motility indices of phases 2, 3, and fed period were 59%, 49%, and 24% of those of control subjects, respectively, and the frequency of contractions of phases 2, 3 and the fed period were 70%, 79%, and 32% of those of control subjects, respectively. In both patients with types II and III FVM, only infrequent low-amplitude contractions were recorded during fasting and after feeding. We concluded that intestinal contractions in patients with familial visceral myopathies were weak, and the weakness was more severe in patients with intestinal pseudo-obstruction syndrome.     

Intracranial pressure parameters in idiopathic normal pressure hydrocephalus patients with or without improvement of cognitive function after shunt treatment

BACKGROUND/AIMS: Previous research has shown improvements in the clinical triad (gait, incontinence and cognitive dysfunction) after shunt surgery in idiopathic normal pressure hydrocephalus (iNPH) patients with intracranial pulse pressure amplitudes >4-5 mm Hg, the pulse amplitudes being <4 mm Hg in the nonresponders. However, it is unknown whether similar differences exist regarding change in cognitive functioning after shunt surgery. The aim of this study was to compare preoperative intracranial pressure (ICP) parameters between iNPH that either improved or not improved in cognitive function after shunt treatment. METHODS: Neuropsychological testing was performed before and after surgery in 27 consecutive iNPH patients treated with ventriculoperitoneal shunts. The ICP recordings were performed as part of routine preoperative assessment, stored as raw data files, and analyzed retrospectively. The mean ICP as well as single ICP wave amplitudes were computed and analyzed in consecutive 6-second time windows. RESULTS: Significant improvement in neuropsychological tests, defined as a 4-point improvement in Folstein Mini-Mental State Examination or improvement by one standard deviation in 50% of subtests of Dementia Rating Scale, was found in 12 patients (44%; shunt responders). In these patients, mean ICP was similar though the mean ICP wave amplitude was significantly higher than in the shunt nonresponders. CONCLUSIONS: While preoperative mean ICP was similar, the mean ICP wave amplitudes were considerably higher in iNPH patients with significant change in cognitive function following shunt surgery.     

Validation of a Fully Automated Analysis of Esophageal Body Contractility and Lower Esophageal Sphincter Function: A Study on the Effect of the PGEI Analogue Rioprostil on Human Esophageal Motility

A new method for automatic analysis of resting lower esophageal sphincter pressure and postdeglutitive motor activity of esophageal body and lower esophageal sphincter (LES) is validated by comparing the results obtained with automatic and manual analysis of 11,700 esophageal body pressure peaks, 390 resting LES pressure measurements, and 3900 LES relaxations. The automatic analysis is based on the on-line transformation of pressure recordings into a mathematical formula using B-spline functions, which allows one to use the same parameters as those generally applied in manual analysis of esophageal manometric recordings. Statistical evaluation of the results indicates that this method provides a faithful analysis of the pressure tracings. The difference between manual and automatic analysis (mean ± SD) was only + 1.49 ± 4.26 mm Hg for wave amplitude, -0.15 ± 0.61 seconds for wave duration, +0.37 ± 1.05 cm/second for progression velocity, +0.95 ± 1.38 mm Hg for resting LES pressure, and -2.0 ± 1.67 mm Hg for residual LES pressure after deglutition. Wave form was correctly recognized in 95.3% of the waves. Pressure recordings were obtained from a study on the effect of the PGE₁ analogue rioprostil (600 and 300 μg), administered orally on esophageal motor function in 10 normal volunteers. The drug increased both the resting LES pressure and the amplitude of esophageal body contractions and decreased the completeness of LES relaxation after swallowing.     

Reactivity of the cerebral circulation in patients with carotid occlusion.

Cerebral blood flow (CBF) and the response to hypercapnia (cerebral reactivity) have been measured in 41 patients with unilateral or bilateral internal carotid artery occlusion in an attempt to identify those with limited collateral reserve. Normocapnic CBF was within normal limits in the majority of subjects. The response to hypercapnia varied from normal to absent, with impaired reactivity becoming increasingly likely when more than one artery was diseased. In 19 patients with unilateral carotid occlusion, hemisphere reactivity was well preserved in the majority, but was significantly lower on the side of the occlusion (mean 2.9%/mm Hg) compared to the normal side (mean 3.4%/mm Hg). Reactivity on the side of the occlusion was further reduced in 15 patients with occlusion and contralateral internal carotid artery stenosis (mean 1.7%/mm Hg) and was even lower in seven patients with bilateral occlusion (mean 1.1%/mm Hg). There was no difference in reactivity between asymptomatic hemispheres in the 41 patients (mean 2.7%/mm Hg) and hemispheres in which a previous stroke had occurred (mean 2.8%/mm Hg). In contrast the response in hemispheres subject to continuing transient ischaemic attacks was significantly impaired (mean 1.6%/mm Hg), suggesting that the cerebral symptoms in some of these patients may have had a haemodynamic origin more often than suspected from the clinical history.     

Evidence that intraluminal pressure affects high potassium- and serotonin-induced contractions differently in the bovine middle cerebral artery: an in vitro study

The effects of changing intraluminal pressure on contractions induced by 70 mM potassium (K+) and 10(-7), 10(-6), and 10(-5) M serotonin (5-HT) were studied in vitro in bovine middle cerebral arteries. Changes in vessel outside diameter in whole-mounted cylindrical sections of artery were detected with a photoelectric infrared device. High K+-or 5-HT (10(-5)M)-induced contractions peaked at 25 mm Hg and were significantly correlated with increasing intraluminal pressure between 25 and 175 mm Hg. Contractions induced with lower concentrations of 5-HT (10(-6), 10(-7) M), norepinephrine, and histamine peaked at 75 mm Hg but were not significantly correlated with rising pressure. Phentolamine (2 X 10(-6) M) added to the extraluminal bath had negligible influence on pressure's ability to affect K+- and 5-HT-induced contractions differently. Reducing bath temperature to 27 degrees C reduced the K+ response at each pressure, but similar temperature changes had little affect on the 5-HT-induced contractions. The K+ response became less sensitive to increasing pressure at low temperatures. Nifedipine (10(-7) M) almost totally eliminated K+-induced contractions, while significantly reducing the responses to all concentrations of 5-HT. The 5-HT responses appeared more sensitive to increasing intraluminal pressure in the presence of nifedipine. Maximum Ca++-induced contractions in the presence of 10(-5) M 5-HT and high K+ occurred at 25 mm Hg, while Ca++-induced contractions and Ca++-induced contractions in the presence of 10(-7) 5-HT or K+ plus 5-HT were maximum at 75 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)     

呼气末二氧化碳分压水平对慢性阻塞性肺疾病患者中枢驱动和呼吸应答的影响

目的 探讨不同呼气末二氧化碳分压(PETCO2)水平对慢性阻塞性肺疾病(COPD)患者巾枢驱动和呼吸应答的影响.方法 13例稳定期COPD患者和10例健康志愿者常规测定肺通气功能后,采用二氧化碳(CO2)重复呼吸方法 ,增加PETCO2,从45 mm Hg上升至70 mm Hg.连续记录并计算在不同PETCO2水甲时中枢驱动和呼吸应答的各项生理参数.结果 PETCO2达到70mm Hg的实验时间在COPD组为(8.5±1.6)min,正常组为(16.3±3.2)min,差异有统计学意义(P＜0.05).两组的呼吸频牢(RR)均呈线性增加,正常组稍高于COPD组.COPD组潮气量(VT和分钟通气量(VE)在PETCO2=45～55 mm Hg时,呈显著的线性增加,VT山(0.68±0.25)L 上升到(1.04±0.44)L,VE由(10.59±3.36)L/min上升到(20.13±4.52)L/min.在PETCO2=55～70 mm Hg时VT和VE出现平台.正常组VT和VE呈线性增加,高于COPD组.正常组的吸气时间占呼吸周期比值(T1/Ttot)高于COPD组,差异有统计学意义(P＜0.05).COPD组的呼吸困难评分高于正常组,差异有统计学意义(P＜0.05).两组的平均吸气流量(VT/Ti)和膈肌电电压的均方根(RMS)均呈线性增加,COPD组VT/T1在PETCO2=65～70mm Hg时低于正常组,差异有统计学意义(P＜0.05),而不同PETCO2水平时RMS高于正常组,差异有统计学意义(P＜0.05).COPD组VE/RMS呈抛物线样变化,明显低于正常组,差异有统计学意义(P＜0.05).结论在CO2重复呼吸过程中,COPD患者的呼吸应答和中枢驱动在早期表现为线性递增,后期通气量出现平台,通气-中枢耦联显著异常.正常组的呼吸应答和中枢驱动均表现为线性递增,呼吸应答高于COPD组,而中枢驱动低于COPD组.     

Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial

BACKGROUND: There is much uncertainty about the effects of early lowering of elevated blood pressure (BP) after acute intracerebral haemorrhage (ICH). Our aim was to assess the safety and efficiency of this treatment, as a run-in phase to a larger trial. METHODS: Patients who had acute spontaneous ICH diagnosed by CT within 6 h of onset, elevated systolic BP (150-220 mm Hg), and no definite indication or contraindication to treatment were randomly assigned to early intensive lowering of BP (target systolic BP 140 mm Hg; n=203) or standard guideline-based management of BP (target systolic BP 180 mm Hg; n=201). The primary efficacy endpoint was proportional change in haematoma volume at 24 h; secondary efficacy outcomes included other measurements of haematoma volume. Safety and clinical outcomes were assessed for up to 90 days. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00226096. FINDINGS: Baseline characteristics of patients were similar between groups, but mean haematoma volumes were smaller in the guideline group (12.7 mL, SD 11.6) than in the intensive group (14.2 mL, SD 14.5). From randomisation to 1 h, mean systolic BP was 153 mm Hg in the intensive group and 167 mm Hg in the guideline group (difference 13.3 mm Hg, 95% CI 8.9-17.6 mm Hg; p<0.0001); from 1 h to 24 h, BP was 146 mm Hg in the intensive group and 157 mm Hg in the guideline group (10.8 mm Hg, 95% CI 7.7-13.9 mm Hg; p<0.0001). Mean proportional haematoma growth was 36.3% in the guideline group and 13.7% in the intensive group (difference 22.6%, 95% CI 0.6-44.5%; p=0.04) at 24 h. After adjustment for initial haematoma volume and time from onset to CT, median haematoma growth differed between the groups with p=0.06; the absolute difference in volume between groups was 1.7 mL (95% CI -0.5 to 3.9, p=0.13). Relative risk of haematoma growth >or=33% or >or=12.5 mL was 36% lower (95% CI 0-59%, p=0.05) in the intensive group than in the guideline group. The absolute risk reduction was 8% (95% CI -1.0 to 17%, p=0.05). Intensive BP-lowering treatment did not alter the risks of adverse events or secondary clinical outcomes at 90 days. INTERPRETATION: Early intensive BP-lowering treatment is clinically feasible, well tolerated, and seems to reduce haematoma growth in ICH. A large randomised trial is needed to define the effects on clinical outcomes across a broad range of patients with ICH. FUNDING: National Health and Medical Research Council of Australia.     

Blood pressure exceeding national guidelines among women after stroke

BACKGROUND AND PURPOSE: After a transient ischemic attack or stroke, the risk for recurrence may be reduced by treatment of hypertension. The purpose of this study was to determine how commonly blood pressure exceeds national guidelines among patients who have had one of these events. METHODS: Subjects were 644 women participating in a randomized trial of estrogen for secondary stroke prevention. We measured blood pressure 1 month after the stroke or TIA while patients were under the care of their personal physicians. Among 536 patients, a second measure was made at an average of 2.9 years after the first. RESULTS: The mean age of participants was 71 years, and 73% reported a history of hypertension. At baseline, only 44% (280/644) of the women had blood pressure values within national guidelines (<140/90 mm Hg). With separate guidelines used for diabetics (<130/85 mm Hg) and nondiabetics (<140/90 mm Hg), the proportions of women within the guidelines were 27% and 44%, respectively. Overall, 39% of patients were within the diabetes-adjusted guidelines. Among patients whose blood pressure exceeded 140/90 mm Hg at first examination, 55% were still in excess at follow-up. Features associated with severe hypertension at first examination (>160/100 mm Hg) were history of hypertension, education less than college, and higher cognitive functioning. CONCLUSIONS: Blood pressure values in excess of national guidelines are common after stroke and TIA, especially among diabetic patients. Efforts to lower blood pressure control may enhance secondary prevention.     

Tremor analysis in two normal cohorts.

OBJECTIVE: Quantitative tremor analyses using almost identical methods were compared between two independent large normal cohorts, to separate robust measures that may readily be used diagnostically from more critical ones needing lab-specific normalization. METHODS: Hand accelerometry and surface EMG from forearm flexors and extensors were recorded with (500 and 1000 g) and without weight loading under postural conditions in 117 and 67 normal volunteers in two different specialty centers for movement disorders in Germany. RESULTS: Tremor amplitude (total power) and frequency fell within a similar range but differed significantly. A significant reduction of tremor frequency under 1000 g weight load (>1 Hz), and a lack of rhythmic EMG activity at the tremor frequency in around 85-90% of the recordings were robust findings in both centers. CONCLUSIONS: The differences in frequency and total power indicate that these measures critically depend on the details of the recording conditions being slightly different between the two centers. Thus each lab needs to establish its own normative data. We estimate that at least 25 normal subjects have to be recorded to obtain normal values. The reduction of tremor frequency under load and lacking tremor-related EMG activity were well reproducible allowing a differentiation of physiological from low amplitude pathological tremor. SIGNIFICANCE: This study provides a framework for more standardized tremor analyses in clinical neurophysiology.     

The defecation reflex in rats: fundamental properties and the reflex center

While pharmacological and physiological studies in rats are now increasing, physiological properties of their defecation have been scarcely investigated. This study was performed to define the properties of defecation in decerebrate rats, with special reference to the pontine defecation reflex center, which has been postulated in dogs. Intraluminal pressure was recorded from the colon and rectum with balloon-pressure transducer method using balloons of 15-20 mm in length and 0.1-0.3 ml in volume. Distention of a balloon in the descending colon and rectum with an additional injection of 0.03-0.1 ml air induced propulsive contractions on the descending colon and rectum. The mean of threshold pressures to induce propulsive contraction was 17.0 +/- 5.8 mm Hg (mean+/-S.E.) in the proximal part and 18.3 +/- 3.3 mm Hg in the distal part of the descending colon, and 11.8 +/- 1.3 mm Hg in the rectum. The maximum amplitude of propulsive contractions was 55 mm Hg in the rectum, 47 mm Hg in the distal part of the descending colon and 38 mm Hg in the proximal part. Similar colorectal propulsive contractions were produced by gastric distention (5-10 ml, 20-30 mm Hg) and electrical stimulation of the anal canal. Contrarily, spontaneous contractions of the proximal colon were suppressed by rectal distention and anal-canal stimulation. These results suggest that the descending colon and rectum, but not the proximal colon, were innervated by the pelvic afferent and efferent fibers mediating the defecation reflex. Pontine transection at the cerebellar peduncle level abolished colorectal propulsive contractions induced by distention of the stomach, descending colon and rectum, and stimulation of the anal canal, although much smaller contractions were still induced after the pontine transection. These results suggest that the pontine defecation reflex center exists and works in rats, as in dogs.     

Corticotropin Releasing Factor (CRF) increases post-prandial duodenal motor activity in humans

The effects of peripherally administered Corticotropin Releasing Factor (CRF) on post-prandial gastrointestinal motility were studied in normal subjects. Pressure activity was monitored for 90 min pre-and 120 min post-prandially in the antrum and duodenum in 8 healthy male volunteers (mean age 45.5 years). Subjects received, on separate days, ovine CRF (0.6 nmol/kg) or vehicle, infused intravenously over 5 min, 15 min after the beginning of the meal. In all subjects, CRF infusion transiently increased the frequency of contractile events to the frequency of the duodenal slow wave (11.7 ± 0.3 cpm). The postprandial duodenal mobility index (MI) after CRF infusion was significantly greater (7.72 ± 0.29) when compared to vehicle infusion (4.34 ± 0.14) (mean ± SEM; P < 0.001). However, the fraction of propagated contractile events was not altered significantly after CRF when compared to vehicle. In contrast, the antral post-prandial MI was not affected by the CRF application. Serum cortisol levels increased significantly at 60 and 90 min post-CRF injection. These data indicate that CRF transiently switches the post-prandial duodenal motor activity to a band of non-propagated high frequency contractions, but does not affect antral contractions.     

Clinical,laboratory and prognostic features of congenital large intestinal motor dysfunction (pseu do-Hirschsprung's disease)

One hundred and forty-eight cases of congenital large intestinal motor dysfunction (pseudo-Hirschsprung's disease) were reported by members of the Japanese Society of Pediatric Surgeons during the past 20 years. The disorder was defined as a congenital, non-mechanical obstruction of the intestine with the presence of intramural ganglia in the terminal rectum. Intramural ganglia were abnormal in 77 cases, normal in 42, and could not be determined in 29. Of those with abnormal intramural ganglia, 54 had immature ganglia or hypoganglionosis (oligoganglionosis), 15 had neuronal intestinal dysplasia, and eight had a segmental anomaly. Of those with a normal myenteric plexus, 22 had chronic and twelve had suspected idiopathic intestinal pseudo-obstruction syndrome; eight had megacystis-microcolon-intestinal hypoperistalsis syndrome. While cases with both hypoganglionosis and normal intramural ganglia had normal acetylcholine esterase activity, a significantly greater number of patients with hypoganglionosis lacked normal rectoanal reflexes. Patients with hypoganglionosis, chronic idiopathic intestinal pseudo-obstruction syndrome, and megalocystis-microcolon-intestinal hypoperistalsis syndrome had poor prognoses with an overall mortality of 36.9%. These findings indicate that congenital large intestinal motor dysfunction remains a serious disease of childhood.     

Evaluation of baroreflex sensitivity by the sequence method using blood pressure oscillations and R-R interval changes during deep respiration

BACKGROUND: Baroreflex sensitivity assessments have been considered to be important to evaluate cardiac autonomic neuropathy. The phenylephrine method, Valsalva maneuver or sequence method at rest caused several problems. We evaluated the usefulness of the sequence method during deep respiration. METHOD: Baroreflex sensitivity was evaluated in 20 normal volunteers and 50 patients with Parkinson's disease. R-R intervals and systolic blood pressures were obtained by electrocardiogram and tonometry using a continuous blood pressure monitoring system. The sequence method is an evaluation of baroreflex sensitivity using sequences of 3 or more consecutive beats for 4 min. Baroreflex sensitivity was also assessed by the Valsalva maneuver at 5 beats before the peak systolic blood pressure of phase IV. The slope of the linear interrelationship between systolic blood pressure and the following R-R interval, i.e. baroreflex sensitivity (ms/mm Hg), was calculated with a correlation coefficient greater than 0.8. RESULT: The mean value of baroreflex sensitivity obtained by the Valsalva maneuver was 7.91 in normal volunteers and 5.35 in patients with Parkinson's disease; the one obtained by the sequence method at rest was 9.10 in normal volunteers and 8.42 in patients with Parkinson's disease, and the one obtained by the sequence method during deep respiration was 10.23 in normal volunteers and 6.73 in patients with Parkinson's disease. In some cases with Parkinson's disease, baroreflex sensitivities could not be found, whereas in all patients with Parkinson's disease, the sequence method during deep respiration could be used for evaluations. Significant correlations were found among the baroreflex sensitivities obtained by the Valsalva maneuver, and the sequence method at rest or during deep respiration in normal volunteers and patients with Parkinson's disease. CONCLUSIONS: The baroreflex sensitivity obtained by the sequence method during deep respiration could be investigated noninvasively in all cases with PD, being thus a useful method for clinical evaluation of baroreflex sensitivity.     

Direct Physical Factors and PGI2 and TXA2 Secretions by a Human Endothelial Cell Line: In Vitro Investigation of Pressure and Shear Stress Applied Independently or in Synergy

The direct effect of two types of mechanical stress was measured through the prostacyclin (PGI2) and thromboxane A2 (TXA2) secretions by a confluent monolayer of cells from the EA.hy926 line. Eight values of constant pressure were applied in the gas phase above the culture medium, around atmospheric pressure taken as a control (0 mm Hg), from −500 to +760 mm Hg. Three amplitudes of sine-wave modulated pressure (±40; ±80; ±160 mm Hg) were explored at a frequency of 1 Hz. Modulated pressure (±40 mm Hg) was also applied synergetically to a shear stress generated under steady state conditions by a rectilinear laminar motion of the medium. The cells remained adherent and exhibited unchanged morphology and viability. Constant pressure or depressure increased both PGI2 and TXA2 release but to an extent depending on the pressure value. Under pressure, the PGI2/TXA2 ratio was unchanged, but was higher under depressure, compared to the control. Pressure modulation strongly stimulated the secretion of PGI2 but had no effect on TXA2. Modulation strongly increased the PGI2/TXA2 ratio to a similar extent for the three amplitudes. Pressure-shear synergy enhanced secretion of PGI2 markedly more than shear stress alone, but the level reached was similar to the one induced by pressure modulation. No cumulative effect on the secretion of PGI2 was observed, whereas TXA2 synthesis undergoes a more than cumulative effect. The PGI2/TXA2 ratio remained unchanged under shear alone or under combined shear-pressure modulation but was higher with the modulated pressure alone. These results demonstrate that pressure has an outstanding effect on secretion that may be origin to local disturbances of the vascular system, thus inducing pathologies such as thrombosis or atherosclerosis.     

Systolic blood pressure within an intermediate range may reduce memory loss in an elderly hypertensive cohort.

The objective of this study was to determine if maintenance of systolic blood pressure (BP) within a high range or low range among treated hypertensive patients increases the risk of memory decline. Biennial neuropsychological evaluations were performed on 158 hypertensive subjects. Decline/year was measured on the Cued Selective Reminding test (total free recall and delayed recall) in three systolic BP groups (low-i.e., mean systolic BP during the follow-up period < 135 mm Hg; intermediate-i.e., 135 mm Hg < or = mean systolic BP < or = 150 mm Hg; high-i.e., mean systolic BP > 150 mm Hg). In total free recall, the three systolic BP groups had significantly different declines per year (P = .02), with patients in the high subgroup showing the greatest decline. In delayed recall, the three systolic BP groups also showed significantly different declines per year (P = .04), with patients in the low subgroup having the greatest decline. Chronically elevated systolic BP > 150 mm Hg is associated with accelerated memory decline compared to older treated hypertensive patients with systolic BP in an intermediate range. Chronically maintained systolic BP within a low normal range < 135 mm Hg in older treated hypertensive subjects may be associated with accelerated memory decline, specifically in a test of delayed memory recall, compared to patients with systolic BP in an intermediate range. Optimal regulation of systolic BP may be a potential modifiable risk factor to prevent or minimize memory loss in older hypertensive patients.     

Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension

Delayed neurologic deterioration from vasospasm remains the greatest cause of morbidity and mortality following subarachnoid hemorrhage. The authors assess the incidence and clinical course of symptomatic vasospasm following subarachnoid hemorrhage using a uniform management protocol over a 24-month period. One hundred eighteen consecutive patients were admitted to the neurovascular surgery service within 2 weeks of subarachnoid hemorrhage not attributed to trauma, tumor, or vascular malformation (113 patients had aneurysms). Early surgery was performed whenever possible, and hypertensive hypervolemic hemodilution therapy was instituted at the first sign of clinical vasospasm. Forty-two patients (35.6%) developed characteristic signs and symptoms of clinical vasospasm with angiographic verification of spasm in 39 cases. All patients with clinical vasospasm received hypervolemic hemodilution therapy aiming for a hematocrit of 33-38%, a central venous pressure of 10-12 mm Hg (or a pulmonary wedge pressure of 15-18 mm Hg), and a systolic arterial pressure of 160-200 mm Hg (120-150 mm Hg for unclipped aneurysms) for the duration of clinical vasospasm. Over the course of treatment, 60% of patients with clinical vasospasm had sustained improvement by at least 1 neurologic grade, 24% maintained a stable neurologic status, and 16% continued to worsen. At the end of hypervolemic hemodilution therapy, 47.6% had become neurologically normal, 33.3% had a minor neurologic deficit, and 19% had a major neurologic deficit or were dead. There were 3 instances of cardiopulmonary deterioration (7%), all of which were in patients without Swan-Ganz catheters, and all resolved with appropriate diuresis. One patient rebled and died while on hypervolemic hemodilution therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dysmotility of the small intestine in achalasia

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.     

Does retrograde axonal atrophy really occur in carpal tunnel syndrome patients with normal forearm conduction velocity?

OBJECTIVE: The cause of decreased median forearm motor conduction velocity (FMCV) in carpal tunnel syndrome (CTS) is best ascribed to retrograde axonal atrophy (RAA); however, the relationships between the occurrence of RAA and electrophysiological or clinical severity remains controversial. We attempt to determine whether RAA really occurs in CTS patients with normal median FMCV and to investigate any relationships between RAA and severity of compression at the wrist. METHODS: Consecutive CTS patients were enrolled and age-matched volunteers served as controls. We performed conventional nerve conduction studies (NCS) and measured median and ulnar distal motor latencies (DML), FMCV, compound muscle action potential (CMAP) amplitudes, distal sensory latencies (DSL), and sensory nerve action potential (SNAP) amplitudes. Furthermore, palmar median stimulation was done to calculate the wrist-palm motor conduction velocity (W-P MCV). Patients included for analysis should have normal FMCV and needle examination. We compared each electrodiagnostic parameters between the patient group and controls. RESULTS: The mean+/-SD of the W-P MCV for patients and controls were 33.26+/-6.74 and 52.14+/-5.85 m/s and those of median FMCV were 55.26+/-3.56 and 57.82+/-3.9 m/s, respectively. There was a significant reduction in the W-P MCV (36.2%, P<0.00001), significant decrease in the median FMCV (4.43%, P<0.00001) and SNAP amplitudes, and an increase of the DML and DSL in the patient group (P<0.00001) compared to the controls; however, there were no differences in median and ulnar CMAP amplitudes, ulnar FMCV and DML between the controls and patients. CONCLUSIONS: RAA and relatively slowed median FMCV do occur in CTS patients with normal median FMCV, regardless of severity of clinical manifestations and electrophysiological abnormalities. SIGNIFICANCE: This article provides new information for research of the electrophysiological changes of the proximal nerve part at distal injury.     

Autonomic dysfunction in patients with chronic intestinal pseudo-obstruction

We prospectively evaluated autonomic function in 50 patients with clinical and manometric features of a neuropathic form of chronic intestinal pseudo-obstruction (CIP). In 26 patients, there were underlying disease processes that may have affected extrinsic neural control to viscera: diabetes mellitus (n = 16), previous gastric surgery (n = 5), and other neurologic disorders (n = 5). Our aim was to characterize autonomic function in these patients, and those 24 with CIP unassociated with a known underlying neurologic disorder (idiopathic group). We assessed vagal function and sympathetic cholinergic and adrenergic function by means of standardized autonomic tests and quantitated postprandial antral pressure activity. We also measured postprandial levels of pancreatic polypeptide and neurotensin as indicators of vagal function and of the delivery of nutrients to the distal small bowel. Among the idiopathic group (n = 24), two had evidence of a generalized sympathetic neuropathy and five abdominal vagal dysfunction (one had both). Among diabetic patients, three had sympathetic adrenergic failure, six had orthostasis with normal plasma noradrenaline, ten had signs of generalized sympathetic neuropathy and eight had abdominal vagal dysfunction. Vagal dysfunction was identified in all three patients who underwent vagotomy as part of their previous gastric survery. In the other neurologic syndromes, vagal function was abnormal in three of the five patients. Thus, autonomic and, particularly, vagal dysfunction are confirmed in a majority of patients with CIP associated with known diabetes or neurologic disorders; however, a previously unrecognized autonomic (chiefly vagal) neuropathy of undetermined cause has been identified in five of the 24 idiopathic CIP patients. Autonomic function should be evaluated in patients presenting with the syndrome of chronic intestinal pseudo-obstruction.     

The electroencephalogram of elderly subjects revisited

The EEGs of 98 elderly volunteers were compared with those of 84 patients with a recent cerebral infarction who had achieved a stable clinical course. All subjects were uniformly evaluated according to a special protocol. The elderly volunteers were accepted for the study if they had no history, signs or symptoms of central nervous system disease. The EEGs were found to be significantly different between the two groups of subjects in several aspects. These included not only possible abnormalities, focal or diffuse, but also some normal features, such as alpha frequency and responses to photic stimulation and to hyperventilation. Groups of these differentiating features were analyzed. Using the single variable of ER (evoked response), discrimination of 80% was achieved. The variables that distinguish the volunteers from the patients may be used in the future to determine whether they are helpful in differentiating normals from patients with conditions other than stroke.