T2 hypointensity in the deep gray matter of patients with multiple sclerosis: a quantitative magnetic resonance imaging study.

CONTEXT: While gray matter T2 hypointensity in multiple sclerosis (MS) has been associated with physical disability and clinical course, previous studies have relied on visual magnetic resonance imaging (MRI) assessments. OBJECTIVE: To quantitatively determine if T2 hypointensity is associated with conventional MRI and clinical findings in MS. DESIGN: Case-control study. SETTING: University-affiliated community-based hospital. SUBJECTS: Sixty patients with MS and 50 controls. MAIN OUTCOME MEASURES: T2 intensities of the substantia nigra, red nucleus, thalamus, putamen, globus pallidus, and caudate; third ventricular width; total brain T1 (hypointense) and T2 (hyperintense) lesion volumes; Expanded Disability Status Scale (physical disability) score; and disease course. RESULTS: Deep gray matter T2 hypointensity was present in patients with MS in all structures (P<.005) except for the substantia nigra. T2 hypointensity was associated with third ventricle enlargement and higher T2 but not T1 plaque load. The regression model predicting third ventricle width included caudate T2 hypointensity (P =.006). The model predicting T2 lesion load included globus pallidus T2 hypointensity (P =.001). Caudate T2 hypointensity was the only variable associated with disability score in regression modeling (P =.03). All T2 hypointensities differentiated the secondary progressive from the relapsing-remitting clinical courses. The final model (P<.001) predicting clinical course retained T2 hypointensity of the thalamus, caudate, and putamen but not MRI plaques or atrophy. CONCLUSIONS: Gray matter T2 hypointensity in MS is associated with brain atrophy and is a stronger predictor of disability and clinical course than are conventional MRI findings. While longitudinal studies are warranted, these results suggest that pathologic iron deposition is a surrogate marker of the destructive disease process.     

Laparoscopic repair of blunt traumatic anterior abdominal wall hernia.

Traumatic abdominal wall hernia is a relatively uncommon finding secondary to blunt trauma. We report a unique case of laparoscopic diagnosis and immediate repair of a traumatic anterior abdominal wall hernia after blunt abdominal trauma.     

Extensive and enantioselective presystemic metabolism of dl-threo-methylphenidate in humans

1. Two pilot studies were carried out to investigate the enantioselective pharmacokinetics of methylphenidate (MPH) in children with attention deficit-hyperactivity disorder (ADHD). A more definitive study, which included administration of an intravenous dose, was carried out in healthy young men. 2. Serial plasma samples were harvested from predose to 8 hours in the first pilot study, predose to 12 hours in the second pilot study and predose to 16 hours in the definitive study. Plasma levels of the separate isomers d-MPH and 1-MPH were determined by an enantioselective gas chromatographic method. 3. In the first pilot study, 6 boys with ADHD each received his regular dose of MPH (10mg n = 5, 5mg n = 1), which contained equal proportions of d-MPH and 1-MPH in an immediate release formulation (MPH-IR). No MPH was detectable in the predose plasma. Thereafter, plasma levels of the more active d-MPH were 4 to 10 fold higher than those of 1-MPH. Plasma levels of 1-MPH were so low that it was not possible to monitor them beyond 4 hours in some children. 4. In the second pilot study, 5 boys and 1 girl with ADHD each received their regular dose (20mg) of a slow release formulation (MPH-SR). No MPH was detectable in the predose plasma. Thereafter, plasma levels of the more active d-MPH were 5 to 10 fold higher than those of 1-MPH. It was possible to monitor plasma levels of 1-MPH over the full 12 hour period of study in 5 of the 6 children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of phosphatidylcholine on intra-abdominal adhesion formation and peritoneal macrophages

Phosphatidylcholine (PC) is the predominant constituent of the surface-active material coating peritoneal mesothelium. Its effects on surgically induced adhesion formation and on peritoneal macrophage viability and superoxide production were studied in rats. Rats treated with intraperitoneal PC liposomes showed more adhesions than controls (p less than 0.01). In vitro incubation with PC had no effect on macrophage viability, but significantly diminished superoxide production (p less than 0.05 and less). It is concluded that PC in its insoluble form is of no value in the prophylaxis of adhesions after abdominal and pelvic surgery and that with the use of the intraperitoneal route it is probably contraindicated in patients undergoing continuous ambulatory peritoneal dialysis.     

Is documentation of TOLAC counseling a good measure of quality of care?

Objective: The objective of this study is to determine whether chart documentation of patient counseling on trial of labor after cesarean (TOLAC) during prenatal care is associated with patient knowledge of risks and benefits of TOLAC and repeat cesarean delivery (RCD).

Study design: Prenatal patients eligible for TOLAC completed a questionnaire that assessed their knowledge of basic maternal and neonatal risks and benefits of TOLAC versus planned repeat cesarean delivery. Patient electronic medical records were reviewed for documentation of TOLAC counseling. Women were included at both early and late time points in pregnancy to include those who both had and had not undergone counseling.

Results: Patients with documented completed TOLAC counseling did not perform better on the knowledge survey. Patients who had documentation of counseling on specific subjects such as TOLAC success rates, risk of uterine rupture, and downstream health risks of cesarean section were no more likely to answer questions on these topics correctly than patients without counseling. However, patients with documented completed counseling generally felt that they were well informed.

Conclusion: Chart documentation of TOLAC counseling was not correlated with patient knowledge. Patients may not be gaining the knowledge from counseling that providers believe is important for informed decision making.     

Transcutaneous bilirubinometry is a reliably conservative method of assessing neonatal jaundice

Objective: In order to reduce invasive testing in newborns prior to discharge, we tested the direction of the correlation between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), the likelihood of missing high TSBs with a raised threshold for confirmatory testing, and also calculated potential cost savings from fewer laboratory testing.

Methods: We performed a cross-sectional analysis of single paired TcB and TSB results measured at 36?±?2?h of life in neonates?≥37 weeks admitted only to the Level 1 nursery. TcB was measured using the BiliChek® meter.

Results: Of the 552 infants, 512 (92.8%) had TSB levels below TcB values. Correlation between TcB and TSB was 0.69. If TSB confirmation was to be performed at 11.7 mg/dL (medium risk threshold for phototherapy), the negative predictive value was 99.4%, with a potential cost savings of $6555.00 ($1500.00 per 100 patients). Of the 495 infants with TcB?<11.7?mg/dL, only 3 had TSB levels higher than 11.7?mg/dL, and none met phototherapy threshold for low risk infants.

Conclusions: TcB screening at our institution has a high negative predictive value, and can be used as a stand-alone test until values are close to phototherapy threshold, thus reducing invasive testing and cost.     

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy

Objective: The objective of this study is to evaluate a woman’s risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy.

Methods: A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed.

Results: Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p?=?0.004 and 0.005, respectively) and hypertension later in life (p?=?0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p?=?0.006 and 0.002, respectively).

Conclusions: Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.