Paradoxical movement in Parkinson's disease.

Patients with Parkinson's disease, although impaired, can sometimes move effectively under visual guidance. The stimuli that often elicit such paradoxical movement are similar to those that relay visual information to the cerebellum. We suggest that many instances of paradoxical movement may be explained by the fact that the pathways relaying those visual stimuli can bypass the damaged basal ganglia and allow an intact cerebellar circuit to be used for visuomotor control.     

Psychometric Validation of the Eortc Core Quality of Life Questionnaire, 30-Item Version and A Diagnosis-Specific Module for Head and Neck Cancer Patients

A cancer-specific self-reporting quality of life questionnaire has been validated. The questionnaire is designed to assess physical functioning, role functioning, cognitive functioning, emotional functioning, social functioning, pain, fatigue, emesis and quality of life by means of multi-item scales, and other disease- and treatment-related symptoms by means of single items. The questionnaire was completed by 126 head and neck cancer patients with a mean age of 67 years. The internal consistency (scale reliability) was satisfactory for all scales but one. Correlations between scales and items assessing the same underlying dimension were also satisfactory. The questionnaire discriminates between patient subgroups and between acute, subacute and late toxicity. Patient compliance was high. The questionnaire provided valuable information, and most of the scales/items functioned well. A few problems were found, especially with the modified visual analogue scales, and minor modifications will be made.     

Surgical relevance of diagnostic imaging techniques in pretherapeutic staging of carcinoma of the esophagus, stomach, colon and rectum

Summary. The increasing spectrum of therapeutic options for tumors of the gastrointestinal tract has resulted in a refinement of the pretherapeutic diagnostic strategies. The diagnostic approach in surgical institutions that are focused on primary surgical resection will therefore be much less sophisticated than in institutions who propose a selective therapeutic approach based on the pretherapeutic tumor stage and prognostic parameters. Pretherapeutic assessment of the depth of tumor infiltration, i. e. the T-category, is essential because most further diagnostic and therapeutic decisions are based on this information. This can today be achieved with a high degree of accuracy by endoscopy and endoscopic ultrasonography. Early T-stages (T1–2) are usually an indication for primary surgical resection and, after exclusion of distant metastases, no further diagnostic studies are required. In patients with locally advanced esophageal, gastric or rectum tumors (T3–4) multimodal therapeutic concepts should be considered. This usually requires additional diagnostic studies. None of the available diagnostic imaging modalities today allows satisfactory pretherapeutic assessment of lymph node metastases. The assumed nodular status should therefore currently not influence therapeutic decisions. Essential is, however, the assessment of distant metastases, since the documentation of distant tumor spread will change the therapeutic approach to a palliative situation. Detailed histologic and molecular-biologic assessment of tumor characteristics is growing in importance. This not only provides therapeutically relevant information regarding tumor grading, but opens the door towards a modern molecular diagnostic approach. It can be expected that in the near future a vast amount of relevant prognostic information can be obtained from endoscopic tumor biopsies, which may soon alter our therapeutic concepts.      

Post-operative progress of dystonia patients following globus pallidus internus deep brain stimulation

In the current era of functional surgery for movement disorders, deep brain stimulation (DBS) of the globus pallidus internus (GPi) is emerging as the favoured intervention for patients with dystonia. Here we report our results in 20 patients with medically intractable dystonia treated with GPi stimulation. The series comprised 14 patients with generalized dystonia and six with spasmodic torticollis. Although comparisons were limited by differences in their respective neurological rating scales, chronic DBS clearly benefited both patient groups. Data conveying the rate of change in neurological function following intervention are also presented, demonstrating the gradual but progressive and sustained nature of improvement following stimulation of the GPi in dystonic patients.     

Factors influencing results of femoropopliteal bypass operations for lower limb ischemia

An ideal way to assess the effectiveness of femoropopliteal bypass procedures is to standardize patient- and surgeon-related variables by randomization. Through statistical analysis of multiple factors influencing patency, limb loss, death rate and hospital stay, the authors reviewed retrospectively 136 bypass procedures performed over 5 years. Variables that contributed significantly to the results were: preoperative symptoms (p = 0.037), graft material used (p = 0.016), age of the patient (p = 0.007), adequacy of runoff (p = 0.041) and smoking postoperatively (p = 0.013). Autogenous vein grafts were superior to prosthetic grafts, the cumulative patency at 5 years being 67.5% and 38.2% respectively. The authors emphasize that all patients needing vascular surgery should be advised to stop smoking, since in this study postoperative smoking increased the probability of limb loss and adversely affected the cumulative patency rate by interaction with other variables such as preoperative symptoms, graft material and age.     

A prospective investigation of pulmonary embolism in women and men.

OBJECTIVE. The aim of this study was to compare, in women and men suspected of pulmonary embolism, the frequency, risk factors, diagnosis, and presentation of pulmonary embolism as well as the accuracy of the ventilation/perfusion scan (V/Q scan) as a diagnostic tool. DESIGN. Data were collected during a prospective study (the Prospective Investigation of Pulmonary Embolism Diagnosis) to establish the accuracy of the V/Q scan compared with pulmonary angiograms. SETTING. Six tertiary medical centers in Massachusetts, Michigan, Connecticut, Pennsylvania, and North Carolina. PARTICIPANTS. Patients suspected of pulmonary embolism for whom a request was made for a V/Q scan or pulmonary angiogram (496 women and 406 men). RESULTS. Women 50 years old and under had a decreased frequency of pulmonary embolism compared with men of that age (16% vs 32%), but there was no difference in patients over 50 years old (Breslow-Day test, P less than .01). Risk factors for pulmonary embolism, the usefulness of the V/Q scan, and 1-year mortality were not different for women and men. Estrogen use in women was not associated with an increased frequency of pulmonary embolism, except in women using oral contraceptives who had undergone surgery within 3 months; four of five (80%) had emboli compared with four of 28 (14%) age-matched surgical patients not using estrogens (P less than .01). CONCLUSION. Women 50 years old and under (even young women using oral contraceptives) who were suspected of having pulmonary emboli and were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis study had a smaller frequency of pulmonary embolism than men of that age, The risk factors for pulmonary embolism were the same for women and men, except that women using oral contraceptives had an increased risk of pulmonary embolism following surgery. Although the V/Q scan was a useful tool in the preliminary evaluation for pulmonary embolism in these women, a pulmonary angiogram was often needed for accurate diagnosis.     

Similar co-stimulation requirements of CD4+ and CD8+ primary T helper cells: role of IL-1 and IL-6 in inducing IL-2 secretion and subsequent proliferation.

Primary murine CD4+ and CD8+ T helper (Th) cells provide help for various immune responses by secreting lymphokines which activate effector cells. The purpose of the present study was to investigate the co-stimulatory signals that, together with T cell receptor (TCR) cross-linking, induce phenotypically distinct primary Th cells to secrete IL-2 and proliferate. We isolated highly purified populations of primary CD4+ or CD8+ T cells and stimulated them in vitro with platebound anti-CD3 mAb. TCR cross-linking by anti-CD3 mAb induced both IL-2 receptor expression and responsiveness to exogenous IL-2, but was not sufficient to induce either IL-2 secretion or T cell proliferation. Rather, for both CD4+ and CD8+ primary Th cells, IL-2 secretion and proliferation required both TCR cross-linking and antigen presenting cell (APC)-derived co-stimulatory signals. Based on G-10 adherence and sensitivity to gamma-irradiation, the APC populations able to induce primary CD4+ Th cells and primary CD8+ Th cells to secrete IL-2 were indistinguishable. In addition, we found that either IL-1 or IL-6 could replace the requirement for APC-derived co-stimulatory signals for IL-2 secretion and proliferation by both primary CD4+ Th cells and primary CD8+ Th cells. Thus, the present study has examined and compared the co-stimulatory requirements of rigorously purified subsets of IL-2-secreting primary CD4+ and primary CD8+ T cells.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical considerations in bypassing coronary arteries with 100% proximal occlusion.

Objective data on the ability of cineangiography to predict the size of reconstituted totally occluded coronary arteries, as well as the clinical outcome of such revascularization, are sparse. Accordingly, we reviewed 200 consecutive cases of coronary revascularization to determine the answers to these questions. Group I patients (n = 57, with 86 totally occluded coronary arteries) had at least one coronary artery with a 100% proximal occlusion that reconstituted distally. Group II patients (n = 143, with 205 subtotally occluded coronary arteries) had 50% to 99% proximal stenosis of at least one coronary artery. Cineangiograms were blindly reviewed to measure the size of the coronary arteries, which were compared with the actual vessel size at operation. In group I, the totally occluded coronary arteries had a cineangiographic size of 1.9 +/- 0.7 mm and an actual size of 1.6 +/- 0.4 mm (p = 0.00004). In group II, the subtotally occluded coronary arteries had a cineangiographic size of 1.8 +/- 0.4 mm compared with an actual size of 1.8 +/- 0.3 mm (p = not significant). The site of bypass grafting was significantly smaller in group I (1.6 +/- 0.4 mm versus 1.8 +/- 0.3 mm; p = 0.00008). The two groups were similar with respect to preoperative and intraoperative parameters. Operative mortalities were similar (group I, 1.8%; group II, 3.5%; p = 0.68). Creatine kinase isoenzyme profiles and electrocardiographic changes were similar, except for a significant late rise of creatine kinase-MB in group I (56.1 +/- 14.7 versus 30.7 +/- 33.7 MIU/mL; p < 0.001). In conclusion, cineangiography significantly overestimates the size of totally occluded coronary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)