Differential Effects of Peripheral Vibration on Motor‐Evoked Potentials in Acute Stages of Stroke

Objective: The excitability of sensorimotor cortex and spinal motoneurones can be modulated by afferent signals arising from the periphery. Low‐ and high‐frequency vibrations activate separate classes of afferent units in the periphery. Low‐frequency vibrations (2–100 Hz) activate the type I fast adapting afferent units (FA‐I), whereas high‐frequency vibrations (60–1000 Hz) preferentially activate the type II units (FA‐II). Muscle spindles are also sensitive to high‐frequency mechanical vibrations. Motor‐evoked potentials (MEP) generated in response to transcranial magnetic stimulation (TMS) can be modulated by afferent signals. However, it is not clear whether these interactions take place at cortical or spinal cord levels. Methods: Cerebrovascular attacks resulting in stroke generally affect both sensory and motor systems. In eight stroke patients with partial motor deficit in the first two weeks of the incident we studies the effects of low‐ (30 Hz) and high‐ (130 Hz) frequency mechanical vibrations on the MEPs obtained in response to TMS. Recordings from the abductor digiti minimi muscle were carried out by TMS of both lesioned and intact hemispheres. Six patients were tested again four to eight weeks after the initial assessment. The results also were compared with data obtained from eight control subjects. MEPs were evoked by 50% above threshold intensities and for each testing condition initially five control MEPs were recorded. This was followed by consecutive MEPs obtained during vibration (N= 5) and between vibrations (N= 5), and the traces were averaged and analyzed. Results: In normal subjects both low‐ (30 Hz) and high‐ (130 Hz) frequency vibration resulted in shortening of MEP latencies. In patients, there was a similar effect on the affected side with 30 Hz, but not with 130 Hz. Stimulation of the intact hemisphere during high‐frequency vibration in the second test revealed a latency shortening, which could be due to central reorganization. The amplitude of MEPs showed a stronger facilitation in the presence of low‐frequency vibration in the early stage of stroke compared with normal subjects. However, in the second test the level of facilitation was reduced, indicating an effect at the cortical level. Conclusions: The results suggest that a cerebrovascular accident influences the modulatory effects of afferent inputs at both spinal and cortical levels, and in time, as reorganization takes place, these altered influences settle towards normal levels.     

Comparison of saline infusion sonohysterography and hysteroscopy in diagnosis of premenopausal women with abnormal uterine bleeding

Objective

The aim of this study was to compare the diagnostic effectiveness of transvaginal sonography (TVS), saline infusion sonohysterography (SIS), and diagnostic hysteroscopy (HS), with the pathologic specimen as a gold standard diagnostic method, in detecting endometrial pathology in premenopausal women with abnormal uterine bleeding.

Study design

This prospective cohort study was conducted at Zeynep Kamil Education and Training Hospital, Istanbul, Turkey, and included 89 premenopausal women. All participants were examined first by TVS, further investigated with SIS and HS, and finally dilatation and curettage was performed when needed. The results obtained from these three methods were compared with the pathologic diagnoses. The positive and negative likelihood ratios (LR+ and LR−) of TVS, SIS and HS were calculated by comparison with the final pathological diagnosis. In addition, area under the curve (AUC) values were also calculated.

Results

Polypoid lesion was the most common abnormal pathology. LR+ and LR− of TVS, SIS, and HS were 3.13 and 0.15, 9.83 and 0.07, 13.7 and 0.02 respectively in detection of any abnormal pathology, and the AUCs of TVS, SIS, and HS were 0.804, 0.920, and 0.954 respectively. When the three procedures were compared with each other separately, HS had the best diagnostic accuracy, and the diagnostic accuracy of HS and SIS was superior to TVS (p₁ = 0.000, p₂ = 0.000). For the detection of polypoid lesions, HS was the most accurate diagnostic procedure (AUC = 0.947), followed by SIS (AUC = 0.894) and TVS (AUC = 0.778).

Conclusion

HS provides the most accurate diagnosis and allows treatment in the same session in premenopausal women with abnormal uterine bleeding.     

The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa

Objective

To evaluate the success rate of the Bakri balloon in the event of uncontrollable hemorrhage due to placenta previa.

Study design

We evaluated 25 patients who were treated with the Bakri balloon who had severe postpartum hemorrhage with placenta previa and failed medical treatment with uterotonic agents.

Results

The Bakri balloon was inserted abdominally during cesarean section in 24 of 25 cases. In only one case was it inserted vaginally. The Bakri tamponade was effective in 22 cases (88%). There were three cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch suture) and one patient needed hysterectomy.

Conclusions

The Bakri balloon is the least invasive, rapid method in the management of bleeding due to placenta previa with minimal complications.     

Zinc sulfate in the prevention of radiation-induced oropharyngeal mucositis: a prospective, placebo-controlled, randomized study

PURPOSE: To determine the effect of oral zinc sulphate supplementation on radiation-induced oropharyngeal mucositis in patients with head-and-neck cancer. MATERIALS AND METHODS: Thirty patients with head-and-neck cancer were randomly assigned to receive either zinc sulfate or placebo. Primary tumors were localized in the larynx in 14 patients, in the nasopharynx in 4, in the oral cavity in 4, in a salivary gland in 1, in the maxillary sinus in 1, in neck nodes (lymphoma presenting primarily) in 3 and in neck metastases from an unknown primary in 3. In the placebo group, 3 patients were excluded; 1 patient died during treatment, 1 left the study, and 1 did not come to the 6 week control visit. The patients were treated with telecobalt radiotherapy at conventional fractionation (2 Gy/fraction, five fractions weekly, for 20-35 fractions within 4-7 weeks). The median radiation dose was 6400 cGy (4000-7000 cGy). Oral mucositis was assessed by two independent physicians, experts in radiation oncology, using the Radiation Therapy Oncology Group Acute Radiation Morbidity Scoring criteria. RESULTS: In the zinc sulfate group, Grade 3-4 mucositis was not detected in any patient; Grade 0 mucositis was detected in 2, and Grade 1 in 8, and Grade 2 in 5 patients. In the placebo group, Grade 2 mucositis was detected in 4 and Grade 3 in 8 patients. We observed that the degree of mucositis in the patients in the zinc sulfate group was significantly lower than that in the placebo group (p < 0.05). Confluent mucositis developed earlier in the placebo group than in the zinc sulfate group after the onset of treatment (p < 0.05) and started to improve sooner in the zinc sulfate group than in the placebo group (p < 0.05). CONCLUSIONS: Zinc sulfate is beneficial in decreasing the severity of radiation-induced mucositis and oral discomfort. These results should be confirmed by additional evaluation in randomized studies with a larger number of patients.     

An EMG screening method (dysphagia limit) for evaluation of neurogenic dysphagia in childhood above 5 years old

Oropharyngeal dysphagia is not rare in older children before the adult age, especially the patients with cerebral palsy. Non-invasive simple tests are needed for the evaluation of children with neurogenic dysphagia including the patients with cerebral palsy. So we aimed to evaluate non-invasive ways to screen for dysphagia in children and the usefulness of this almost new electrophysiologic method for the detection of dysphagia in children with cerebral palsy. Twenty-eight healthy children and 12 patients with cerebral palsy were investigated for the applicability of this method. The movement of the larynx was monitored using a simple piezoelectric wafer sensor and submental surface EMG activity was recorded by bipolar silver-chloride electrodes taped under the chin over the submental muscle complex. The onset and duration of pharyngeal swallowing was recorded from submental-suprahyoid muscles such as the mylohyoid-genitohyoid-anterior digastric complex. By this method, the maximal water volume capacity was measured in single swallows with progressively increasing water volumes, this was called 'dysphagia limit'. The healthy control children revealed to swallow the bolus at once maximally 11.2+/-0.4 and 2.5 ml in average. Dysphagia limit varied from 7 to above 20 ml water volume from age 5-16 years old. Patients with cerebral palsy had the dysphagia limit of 7.7+/-1.8 and 6.4 ml in average. The dysphagia limit was significantly reduced in patients with cerebral palsy (p<0.05). Dysphagia limit seemed to be less sensitive in demonstrating the oropharyngeal swallowing disorders in childhood period (90% in the adult dysphagic patients). But the majority of patients with cerebral palsy (58%) showed abnormality. This electrophysiologic method is completely non-invasive, devoid from any hazard and applicable to children above 5 years. It may be candidate as a screening test before selection of dysphagic children.     

X-linked bulbospinal muscular atrophy (Kennedy's syndrome): a report of three cases

Two cases of X-linked bulbo-spinal muscular atrophy and one sporadic case with the same clinical features are presented. All three cases were extensively studied by electrophysiological methods. One of the patients showed some transient weakness, which was partly improved by pyridostigmin. In this patient the Decrement test and jitter revealed a mild degree of motor-end plate dysfunction. Clinical and electrophysiological findings obtained from all three patients suggest that in Kennedy syndrome cell bodies of group IA muscle afferents are also affected selectively, with other peripheral afferents.     

An electronic device measuring the frequency of spontaneous swallowing: Digital Phagometer

A new and protable electronic device called the Digital Phagometer is described for the time-based counting of spontaneous swallowing. This device is composed of a piezoelectric sensor and a digital event counter/recorder which can be downloaded to any IBM-compatible PC. The sensor of Digital Phagometer is placed and fixed on the coniotomy region between the cricoid and thyroid cartilage. In this way, it is capable of sensing each upward and downward movement of the larynx produced by spontaneous movement as a function of time. Spontaneous swallowing was measured 1–4 h after lunch in 21 normal subjects and 21 patients with Parkinson's disease (PD). The mean frequency of spontaneous swallowing was 0.8 counts/min in PD patients and 1.18 counts/min in normal subjects (p<0.05). During the intake of 200 ml water, the mean frequency of voluntary swallowing did not differ significantly between the two groups (24.6 counts/min in normals vs. 22.3 counts/min in PD patients), but the time necessary to swallow the same volume of water was longer in the PD group.     

Palatine tonsil volume estimation using different methods after tonsillectomy

This study was carried out to measure the volume of the palatine tonsil in otorhinolaryngology outpatients with complaints of adenotonsillar hypertrophy and chronic tonsillitis who had undergone tonsillectomy. To date, no study has investigated palatine tonsil volume using different methods and compared with subjective tonsil size in the literature. For this purpose, we used three different methods to measure palatine tonsil volume. The correlation of each parameter with tonsil size was assessed. After tonsillectomy, palatine tonsil volume was measured by Archimedes, Cavalieri and Ellipsoid methods. Mean right–left palatine tonsil volumes were calculated as 2.63 ± 1.34 cm³ and 2.72 ± 1.51 cm³ by the Archimedes method, 3.51 ± 1.48 cm³ and 3.37 ± 1.36 cm³ by the Cavalieri method, and 2.22 ± 1.22 cm³ and 2.29 ± 1.42 cm³ by the Ellipsoid method, respectively. Excellent agreement was found among the three methods of measuring volumetric techniques according to Bland–Altman plots. In addition, tonsil grade was correlated significantly with tonsil volume.     

Epidural lornoxicam administration -- innocent.

We aimed to determine the analgesic efficacy and clinical or histopathological neurotoxicity of epidural single-dose lornoxicam. Caudal epidural catheters were inserted into 28 rabbits, divided into four groups, on day 1. Pain latency and degree of motor and sensory loss for each animal for different concentrations of lornoxicam were determined on day 2. All animals were sacrificed on day 3 and laminectomy was performed. Five-mum thick sections of spinal cord, obtained from two segments caudal and two segments rostral from tip of the catheter, were fixed and were stained and evaluated by light microscopy. Lornoxicam produced dose-dependent analgesia (increase in pain latency), brief, mild and reversible motor and sensory block, and histopathological signs of neurotoxicity. Clinical application of epidural lornoxicam should proceed with caution.