Multiple sclerosis presenting as ataxic hemiparesis

Multiple sclerosis (MS) can present with many clinical pictures, but only rarely as a lacunar syndrome. The following case presentation is of multiple sclerosis with initial presentation as ataxic hemiparesis (AH), indistinguishable from the vascular syndrome. This case serves to illustrate that even classic lacunar syndromes can actually be the initial manifestation of multiple sclerosis and that other etiologies besides ischemic stroke need to remain in the differential diagnosis until a definitive has been concluded.     

Repetition of an unusual stress fracture in an anorexic man: a case report

Stress fractures of the fibula commonly occur distally in runners, whereas stress fractures of the proximal fibula are uncommon and typically occur in jumpers. Furthermore, it is rare for a stress fracture to be repeated in the same bone. We report a case of a repeated stress fracture of the proximal fibula in a male runner with abnormal gait that primarily involved excessive pronation. Unusual risk factors in this case were anorexia nervosa and use of an inhaled corticosteroid. The patient was treated conservatively, and healing of the fracture was completed at 12 weeks.     

An update on functional electrical stimulation after spinal cord injury

Recent advances in biomedical engineering as applied to neurologic rehabilitation have finally borne clinically relevant fruit. Nowhere is this more evident than in the field of functional electrical stimulation (FES). This article highlights the remarkable clinical progress that has been made in the use of electrical stimulation for restoring movement and function in individuals with spinal cord injury. Specific attention is given to respiratory-assist devices, hand-grasp systems, standing and walking, and bladder control. This review article features discussion of eight devices that have gone through the United States Food and Drug Administration (FDA) regulatory approval process.     

Event-related brain potentials (ERPs) in schizophrenia for tonal and phonetic oddball tasks.

BACKGROUND: Prior studies using simple target detection ("oddball") tasks with pure tones have reported asymmetric reduction of the P3 event-related potential (ERP). This study investigated the time course and topography of ERPs recorded during both tonal and phonetic oddball tasks. METHODS: Event-related potentials of 66 patients (14 unmedicated) diagnosed with schizophrenia (n = 46) or schizoaffective disorder (n = 20) and 32 healthy adults were recorded from 30 scalp electrodes during two oddball tasks using consonant-vowel syllables or complex tones. Overlapping ERP components were identified and measured by covariance-based principal components analysis. RESULTS: Schizophrenic patients showed marked, task-independent reductions of early negative potentials (N1, N2) but not reduced P3 amplitude or abnormal P3 asymmetry. Task-related hemispheric asymmetries of the N2/P3 complex were similar in healthy adults and schizophrenic patients. Poorer task performance in patients was related to ERP amplitudes, but could not account for reductions of early negativities. CONCLUSIONS: The findings suggest that both patients and control subjects activated lateralized cortical networks required for pitch (right frontotemporal) and phoneme (left parietotemporal) discrimination. Task-independent reductions of negativities between 80 and 280 msec after stimulus onset suggest a deficit of automatic stimulus classification in schizophrenia, which may be partly compensated by later effortful processing.     

Strategic management simulations is a novel way to measure resident competencies

BACKGROUND: The Strategic Management Simulation (SMS) has been used extensively to test and train higher cognitive functions in persons who occupy professional and leadership positions (i.e., skills like those needed by a surgeon). METHODS: The SMS was used to predict surgical residents' competency in decision making. Skills required for integrative surgical decision making including critical thinking, crisis management, flexibility, factual knowledge, and team building were assessed. Surgical residents with at least 2 years of experience participated. In additional, attending faculty familiar with the residents' work evaluated each resident with a standard comprehensive rating scale. Simulation performance on multiple measures was compared with faculty ratings. RESULTS: A number of measures obtained on simulation performance (eg, activity level, response speed, initiative, adequate usage of and appropriate search for relevant information) generated high correlations with comprehensive faculty assessment (eg, measures of crisis management, team interactions, flexibility of approach). CONCLUSION: The simulation technique is able to accurately assess performance of surgical residents (on a number of parameters) in a relatively brief time period. Simulation data were highly similar to faculty ratings that were based on at least 2 years of experience with the resident.     

New paradigms and improved results for the surgical treatment of acute type A dissection

OBJECTIVE: To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. SUMMARY BACKGROUND DATA: Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. METHODS: From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). RESULTS: Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. CONCLUSION: The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.     

Efficacy of open-label nefazodone treatment in patients with panic disorder

Fifteen patients with panic disorder participated in a 12-week treatment trial with open-label nefazodone. Nefazodone was well-tolerated with minimal side effects; none of the patients reported sexual dysfunction, and only one patient experienced weight gain. Although the response rate was lower than that found with most other antipanic medications, given its favorable side effect profile, nefazodone may be a good alternative for patients apprehensive about potential adverse drug reactions.     

The natural history of microalbuminuria in adolescents with type 1 diabetes

OBJECTIVE: To describe the natural history of urinary albumin excretion measured initially during the first decade of type 1 diabetes in adolescents and to identify predictors of the onset and progression of microalbuminuria (MA) in this population.STUDY DESIGN: A retrospective cohort follow-up study was done on 76 adolescents whose albumin excretion rate (AER) had been determined in the first decade of their diabetes. Subjects were monitored for a mean of 6 years after initial AER testing. Those with MA were compared with a group with similar age, sex, and diabetes duration who initially had normoalbuminuria (NA). RESULTS: Of the 28 with initial MA, 9 (32%) regressed (8 to within the NA range), whereas MA was persistent in 10 (36%) and progressed in 9 (32%), 5 to overt proteinuria. Of the 47 who had initial NA, MA developed in 14 (30%) and overt proteinuria in 3 (6%). With MA status at follow-up as the dependent variable, multiple regression analysis showed that initial AER (P =.0002) and hemoglobin A1c (P =.02) measured at the same time were significant independent variables. CONCLUSIONS: These data suggest that in adolescents: (1) MA detected in the first decade of disease will persist or progress in the second decade in approximately two thirds of patients, and new MA will develop in a third of those initially normoalbuminuric; and (2) the appearance, persistence, or progression of MA is influenced in large part by metabolic control assessed by hemoglobin A1c both at initial MA screening and throughout the course of diabetes. This underlines the need for MA screening starting early in the course of type 1 diabetes in adolescents and for maintenance of good metabolic control.     

Inspiratory muscle strength and endurance during hyperinflation and histamine induced bronchoconstriction.

BACKGROUND: This study investigated whether the inspiratory muscles are susceptible to fatigue during acute airway narrowing because of increased airway resistance and hyperinflation. METHODS: Asthmatic subjects performed up to four series (on separate days) of 18 maximal static inspiratory efforts of 10 seconds' duration with 10 second rest intervals (50% duty cycle; total duration six minutes): at functional residual capacity (FRC) (control); after histamine induced bronchoconstriction, which decreased forced expiratory volume in one second (FEV1) to a mean of 55% (SD 11%) of the initial value; at a voluntarily increased lung volume (initial volume held at 140% control); and after inhalation of histamine at a voluntarily increased lung volume. RESULTS: For the group of subjects the mean (SD) maximal inspiratory pressure (MIP) in the control experiments was 114 (22) cmH2O and the initial volume was 3.5 (1.2) 1. After histamine inhalation the initial lung volume for contractions increased to 118% (5%) of the control volume. In the high lung volume experiments initial volumes were 140% (12%) of the control (volume without histamine) and 140% (15%) (with histamine). The relation between MIP and initial absolute lung volume was determined for each subject before fatigue developed. When the inspiratory pressures for each contraction in the endurance test were normalised to the pressure expected for that lung volume, no significant differences were found between the four experimental conditions for MIP, or between pressures sustained over the 18 contractions. CONCLUSIONS: Histamine induced bronchoconstriction and hyperinflation had no detectable effect on inspiratory muscle strength or endurance in these asthmatic subjects.