Primary headache care delivery by nonspecialists in Brazil

Headaches are common disorders usually examined by nonneurologists. In order to assess how primary headache patients (IHS groups 1, 2, and 3) are generally managed by nonspecialists, 414 patients were asked about their previous headache care. Correct diagnosis had previously been made in only 44.9%, 6.7%, and 26.7% of the migraine, tension-type headache, and cluster headache patients, respectively. The patients underwent 501 investigative procedures motivated by the headache, averaging 1.21 examinations per patient, mostly EEGs. Preventive treatment was largely overlooked irrespective of the headache type. It is concluded that scientific improvements in headache care may be ineffective unless educational programs improve headache knowledge in general.     

Amplatzer封堵器的生物学性能及经导管介入治疗房间隔缺损

目的:评价经导管置入Amplatzer封堵器治疗继发孔房间隔缺损的治疗效果。方法:①选择2002-08/2006-04在兰州市第一人民医院心外科住院的继发孔型房间隔缺损65例,男26例,女39例;平均年龄(18±8)岁;平均房间隔缺损直径(19.3±7.2)mm。纳入患者对手术方案知情同意。②手术所用封堵器为美国公司的Amplatzer房间隔缺损封堵器,是一种新型的适于关闭二孔型房间隔缺损的装置,它由具有自膨胀性的双盘及连接双盘的腰部三部分组成。双盘状结构恢复记忆形状后可以稳定封堵房间隔缺损的边缘部分,降低残余分流的发生率。③根据选择封堵器大小的方式(即球囊测量或经胸超声心动图直接观察)将患者分为球囊测量组38例和经胸超声心动图测量组27例。均在透视及经胸超声心动图监视下经导管置入Amplatzer封堵器封堵房间隔缺损。同时测量患者缺损扩张直径、封堵器大小,记录X射线透视时间和手术时间。④术后即刻、24h、3个月及1年分别行经胸超声心动图、心电图及X射线检查评价治疗效果。⑤超声心动图显示完全无分流为无分流;残余分流血流宽度≤1mm为微量分流;血流宽度1.0～2.0mm为少量残余分流;血流宽度2～4mm为中量残余分流;血流宽度>4mm为大量残余分流。⑥组间计量资料差异比较采用两个独立样本t检验,组间手术效果比较采用两个独立样本的等级资料秩和检验。结果:①技术成功率:65例房间隔缺损患者,64例封堵器置入成功,技术成功率为98%。②选择封堵器直径:球囊测量组缺损扩张直径为(20.4±6.1)mm,选择的封堵器直径为(21.6±5.7)mm,与经胸超声心动图测量组相近[(22.5±4.3),(25.1±4.9)mm,P>0.05]。③术后残余分流情况:术后即刻经胸超声心动图显示,球囊测量组35例完全无分流,经胸超声心动图组有23例,差异不明显(P>0.05);术后24h,球囊测量组36例完全无分流,经胸超声心动图组有24例,差异不明显(P>0.05);术后3个月,球囊测量组37例完全无分流,经胸超声心动图组有25例,差异不明显(P>0.05);术后1年完成随访的52例患者均未见封堵器移位及房间隔缺损再通。④X射线平片检查:全部显示肺血减少,右心房、室缩小。结论:封堵器直径比球囊测量的房间隔缺损扩张直径大1.0～2.0mm,比超声心动图测量的大2～6mm封堵效果好,成功率高。     

In-111-labeled white blood cell uptake in noninfected closed fracture in humans: prospective study

Since indium-111 white blood cell (In-111 WBC) scintigraphy is often used to evaluate for osteomyelitis in bone fractures, it is important to know if noninfected fractures have In-111 WBC uptake. Twenty-seven noninfected closed fracture sites in 19 patients were prospectively evaluated with technetium-99m methylene diphosphonate bone scintigraphy and In-111 WBC scintigraphy. In-111 WBC uptake was present in 41% of the 27 sites. In the 11 positive sites, the In-111 WBC uptake was 1+ (definite but minimal) in 55%, 2+ (moderate) in 36%, and 3+ (marked) in 9%. The visual intensity of the radioactive uptake on In-111 WBC scintigrams relative to that on bone scintigrams was less in 82%, equal in 9%, and greater in 9%. The visual size of the area of uptake on In-111 WBC scintigrams and bone scintigrams was smaller in 36%, equal in 55%, and greater in 9%. Factors that may help distinction of In-111 WBC uptake due to fracture alone from infection associated with fracture are discussed.     

CVA3 Adherence to Hypertension Therapy: The Effect of Initial Drug Choice

Health-care case management places pressure on decision makers to adopt treatment strategies that promote economic efficiency and hence profitability. Traditional costeffectiveness analysis (CEA), where the objective is to calculate cost-effectiveness ratios, can better inform decision making in markets where prices and efficacy vary widely. However, the threshold at which a given therapy becomes economically efficient relative to competing therapies is not evident from cost-effictiveness ratios alone.
OBJECTIVE: To illustrate the use of spatial techniques for identifying efficient treatment options, using statin therapy in secondary prevention of coronary heart disease (CHD) as a case study.
METHODS: We used a Markov model of CHD epidemiology and treatment to estimate cost-effectivness of 13 statin regimens versus no therapy in secondary prevention of CHD. Comparative efficacy was assessed using data from a recent trial (CURVES) that included these regimens. Patients were assumed to have a history of CHD with risk factors similar to those observed in the trial. CHD event risk was estimated using new subsequent-event risk equations from the Framingham Heart Study. Effectiveness was measured alternatively as gain in life expectancy and CHD events averted.
RESULTS: At usual starting doses, atorvastatin therapy provided the largest life expectancy gain and CHD event avoidance at the lowest cost per life-year gained ($12,900 and $23,400 for men and women, respectively), followed by simvastatin ($17,700 and $31,700), lovastatin ($18,800 and $33,700), pravastatin ($22,600 and $40,200), and fluvastatin ($23,800 and $42,000). Any desired level of effectiveness can be obtained at lowest cost with atorvastatin.
CONCLUSION: Economic efficiency is enhanced when atorvastatin is used to treat some or all patients requiring statin therapy in secondary prevention of CHD.     

Ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) in adults is proving to be useful. The aim of this study was to determine if ABPM is accurate in the lower blood pressure range encountered in children and, equally important, whether it is acceptable to children. Thirty one children, between the ages of 6 and 18 years, were assessed using an ambulatory blood pressure monitor that uses an auscultatory method. Blood pressure was measured in the contralateral arm with a mercury sphygmomanometer and an oscillometric device at the beginning and end of the study for comparison. Over a blood pressure range of 90-130 mm Hg systolic and 40-80 mm Hg diastolic, a close agreement was found with the sphygmomanometer; the limits of agreement (+/- 2 SD) were 11.6 mm Hg for systolic blood pressure and 13.6 mm Hg for diastolic blood pressure. The bias was less than 1.0 mm Hg. The ambulatory device was worn by all patients for at least 16 hours with an average of 52 recordings per patient. The majority found the device comfortable to wear and were not woken from sleep.     

Terminal deoxynucleotidyl transferase (TdT)-positive cells in cerebrospinal fluid and development of overt CNS leukemia: a 5-year follow-up study in 113 children with a TdT-positive leukemia or non- Hodgkin's lymphoma

We investigated whether an indirect nuclear terminal deoxynucleotidyl transferase (TdT) immunofluorescence (IF) assay on single cells present in the cerebrospinal fluid (CSF) is more effective than conventional cytomorphology for early detection or exclusion of (minimal) meningeal leukemic infiltration in patients with a TdT+ malignancy. During a 5- year follow-up study, 1,661 consecutive CSF samples from 113 children with a TdT+ acute lymphoblastic leukemia (ALL) (n = 100), a TdT+ acute nonlymphoblastic leukemia (ANLL) (n = 8), or a TdT+ non-Hodgkin's lymphoma (NHL) (n = 5) were analyzed. In 1,511 (91.9%) of 1,643 evaluable CSF samples, the positive and negative findings of both cytomorphology and the TdT-IF assay were concordant. In 47 (2.9%) samples from 28 patients, the cytomorphology was suspect while the TdT- IF assay was negative; follow-up as long as 58 months revealed no CNS leukemia in any patient. In 85 (5.2%) samples, cytomorphology was negative (n = 70) or suspect (n = 15) but TdT+ cells were detected. RBC contamination seriously hampered evaluation in 31 of these 85 samples. From the remaining 54 TdT+ samples from 29 patients, 40 samples preceded overt CNS leukemia in 20 patients. Two consecutive findings of TdT+ cells in the CSF were always followed by overt CNS leukemia. At initial diagnosis, 11 children had TdT+ cells in their RBC-free CSF. In one of these children, morphology was suspect; a repeated lumbar puncture was positive on both assays. Thus, initial CNS leukemia was diagnosed. In the other ten children, morphology was negative. In six of them, CNS leukemia was diagnosed 2 to 20 months later. In 32 other children examined at initial diagnosis, neither TdT+ cells nor blasts were observed in the CSF. In none of these patients was a CNS leukemia diagnosed after a follow-up of 2.5 to 57 months (median 24 months). In 207 control CSF samples from 58 children with TdT- oncologic, hematologic, or infectious diseases, no TdT+ cells could be detected. The TdT-IF assay is easy to perform and is a more reliable diagnostic tool for detection of CNS leukemia at an early stage than is cytomorphology. At initial diagnosis, the finding of Tdt+ cells in a RBC-free CSF sample with a negative cytomorphology is highly predictive for development of overt CNS leukemia.     

SELECTIVE IgA DEFICIENCY PRESENTING WITH HYPERSPLENISM

SUMMARY A young patient presenting with splenomegaly and hypersplenism was inadvertently found to have selective IgA deficiency. There were no symptoms of immunodeficiency and the patient responded well to splenectomy, with return of blood counts to normal without adverse effects. No other cause for the hypersplenism was found. We postulate selective IgA deficiency as a cause of splenomegaly and hypersplenism.     

言语流畅的测量及其神经生理基础

目的:介绍言语流畅性的测量工具,考察言语流畅性与记忆之间的关系,探讨言语流畅性的神经生理基础。资料来源:应用计算机检索Sciencedirect 1975-07/2005-05中与言语流畅性相关的文献,检索词为“verbal fluency”,限定文章语言种类为英文。资料选择:对资料进行初审,选取文章标题中含有“verbal fluency”的英文文献。纳入标准:①对言语流畅性测量任务的研究。②对言语流畅性与记忆的研究。③对言语流畅性神经生理基础的研究。资料提炼:共收集到651篇关于言语流畅性的文章,纳入30篇用于本综述。资料综合:测量言语流畅性的任务主要分为简单任务(包括音位流畅性任务和语义流畅性任务)与复杂任务(包括可能工作、替代使用、草拟、推断、物品制作以及新的使用方法等)。言语流畅性任务的完成主要涉及到记忆搜索的过程,另外,精细组织的语义网络系统对于言语流畅性任务来说也是非常重要的。言语流畅性的神经生理基础包括了总体基础,前额叶,海马以及大脑两半球的不对称性。结论:言语流畅性作为人类语言基本技能的一项指标,对语言认知研究具有极其重要的意义。它不仅是神经心理研究的一项非常重要的检测和诊断指标,也是一种研究人类心理的非常有用的研究工具,是探索人类语言与认知、创造之迷进而探索人类意识之迷的钥匙。     

碱性成纤维细胞生长因子对大鼠脑血肿周围组织和海马bax及bcl-2基因表达的调节

目的:观察碱性成纤维细胞生长因子对大鼠脑出血后出血灶周围脑组织和出血侧海马bax、bcl-2基因表达的影响,探讨神经营养因子对神经细胞调亡的调控。方法:实验于2006-01/10在广西医科大学医学科学实验中心完成。①取成年清洁级Wistar大鼠72只,雌雄各半,体质量250g左右。②采用脑内囊注射胶原酶建立大鼠脑出血模型,动物于苏醒后按Bederson法进行神经病学评分,评分>3分后入选本实验,入选72只大鼠随机抽签法分为3组,每组24只。碱性成纤维细胞生长因子组按8μg/kg剂量肌肉注射,1次/d;生理盐水组肌肉注射等剂量的生理盐水,1次/d;模型组不作任何干预。③每组分别于干预后1,3,7d随机抽取8只大鼠,麻醉状态下取出血灶周围脑组织和出血侧海马,采用半定量反转录-聚合酶链反应检测调亡调控基因bax mRNA,bcl-2mRNA的表达。结果:在建立脑出血模型中共5只大鼠死亡,随后对死亡动物进行解剖,发现脑内血肿量过大,致脑疝形成而导致死亡,后随机补充动物。72只大鼠进入结果分析。①血肿周围脑组织bax mRNA表达:干预后3d,7d,碱性成纤维细胞生长因子组血肿周围脑组织bax mRNA表达比生理盐水组明显减少(3d:0.54±0.19,0.76±0.23,P<0.05;7d:0.45±0.19,0.71±0.16,P<0.01)。②血肿周围脑组织bcl-2mRNA表达:干预后3d,7d,碱性成纤维细胞生长因子组的血肿周围脑组织bcl-2mRNA表达比生理盐水组明显增高(3d:0.68±0.25,0.39±0.19,P<0.05;7d:0.80±0.21,0.48±0.18,P<0.01)。③出血侧海马bax mRNA表达:干预后3d和7d,碱性成纤维细胞生长因子组的出血侧海马bax mRNA表达比生理盐水组均明显减少(3d:0.54±0.18,0.70±0.11;7d:0.43±0.24,0.69±0.18,P均<0.05)。④出血侧海马bcl-2mRNA表达:干预后3d和7d,碱性成纤维细胞生长因子组的出血侧海马bcl-2mRNA表达比生理盐水组均明显增多(3d:0.66±0.11,0.50±0.15;7d:0.72±0.12,0.52±0.22,P均<0.05)。结论:碱性成纤维细胞生长因子能调节凋亡相关基因,提高大鼠脑出血后大脑脑组织和海马bcl-2mRNA的表达,降低bax mRNA的表达。