Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment

Objectives: To identify patients with benign paroxysmal positional vertigo (BPPV) among patients with severe traumatic brain injury (TBI) and to evaluate the effectiveness of the Particle Repositioning Maneouvre (PRM).

Design and methods: Eighteen months prospective study of 150 consecutive patients with severe TBI referred to an in-patients rehabilitation department.

Interventions: A structured interview emphasizing the possible presence of vertigo followed by a detailed neuro-otological examination. Patients diagnosed with BPPV were immediately treated with the PRM.

Main outcomes and results: BPPV diagnosis was based on a positive Dix-Hallpike positional test. PRM efficacy was determined by repeating the positional test 1 or 2 weeks after treatment. Twenty out of 150 (13.3%) patients complained about positional vertigo. The diagnosis of BPPV was confirmed in 10 patients. Signs and symptoms were completely relieved in six patients after a single PRM, while the other four patients needed repeated treatment for complete resolution of BPPV.

Conclusions: About half of the patients with severe TBI who complain about positional vertigo suffer from BPPV. These patients can be efficiently treated by physical maneouvres improving the rehabilitation outcome.     

Erythropoietin in heart failure

The incidence of both congestive heart failure (CHF) and end-stage renal disease both are increasing. Anemia is common in both conditions and is associated with a marked increase in mortality and morbidity in both CHF and chronic kidney insufficiency (CKI). Each of these 3 conditions can cause or worsen the other 2. In other words, a vicious circle frequently is present in which CHF can cause or worsen both anemia and CKI, in which CKI can cause or worsen both anemia and CHF, and in which anemia can cause or worsen both CHF and CKI. We have called this vicious circle the cardio renal anemia syndrome. Optimal treatment of CHF with all the recommended CHF medications at their recommended doses will, in our experience, frequently fail to improve the CHF and CKI if anemia is present and is not corrected. On the other hand, correction of the anemia with subcutaneous erythropoietin and intravenous iron has caused a great improvement in the CHF including a marked improvement in patient and cardiac function and a marked reduction in the need for hospitalization and for high-dose diuretics. It also frequently has caused renal function to improve or at least stabilize. In addition, patients' quality of life and exercise capacity also have improved with the correction of the anemia. In CKI patients, anemia also may play an important role in increasing the risk for death, coronary heart disease, stroke, and progression to end-stage renal disease. Erythropoietin may have a direct positive effect on the heart and brain unrelated to correction of the anemia by reducing cell apoptosis and by increasing neovascularization, both of which could prevent tissue damage. This could have profound therapeutic implications not only in CHF but in the future treatment of myocardial infarction, coronary heart disease, strokes, and renal failure.     

In vitro synthesis of antibody to specific bacterial lipopolysaccharide by peripheral blood mononuclear cells from patients with alcoholic cirrhosis.

An enzyme-linked immunosorbent assay was used to detect antibody to specific bacterial lipopolysaccharide (LPS) in serum and in pokeweed mitogen (PWM) stimulated culture supernatants of peripheral blood mononuclear cells from four patients with alcoholic cirrhosis (AC). Antibody to LPS (derived from a single strain of Escherichia coli isolated from each patient's stool), was detected in the sera of each patient to a 10(-4) dilution. Only one of four control sera was positive at the 10(-4) dilution, with the others positive at 10(-3) dilution. Antibody to LPS was detected in the culture supernatants in three of the four patients and in none of the control subjects. Supernatants from patient cultures pretreated with mitomycin C or harvested after 1 day of incubation did not have detectable antibody. These results indicate that we can expand, in vitro, the population of peripheral blood B lymphocytes obtained from patients with AC and cause them to synthesize antibody against specific LPS from their own gut flora.     

Screening for hypertension in high school

Arterial hypertension is a major risk factor for atherosclerotic ischemic heart disease and cerebrovascular stroke. Blood pressure measurements were taken in the supine position in 6,282 healthy adolescents (3073 boys, 3209 girls) aged 13-17 years of both sexes. Forty-eight subjects were found to have hypertension: 35 idopathic and 13 secondary to reflux nephropathy, chronic glomerulonephritis, coarctation of the aorta, and hemolytic uremic syndrome. Systolic blood pressure was significantly higher among males than females at ages 15-17 years (p<0.001); diastolic blood pressure was higher among males at age 17 years only (p<0.05). Males with BMI>17 exhibited higher systolic blood pressure than females. Prevalence of hypertension, mostly primary, in a large cohort of students was 0.76%. Early screening is important for early interventions and reducing cardiovascular morbidity and mortality in adulthood.     

Poly I-C induces early embryo loss in f344 rats: a potential role for NK cells

PROBLEM: Natural killer (NK) cells were associated with first trimester embryo loss. The current study in the inbred F344 rat assessed the role of NK cells in mediating resorptions caused by poly I-C, a non-specific immunostimulator. METHOD OF STUDY: On fifth day of gestation, rats were injected intraperitoneally with anti-NKR-P1 (1.5 mg/kg, i.p.) to deplete NK cells, and with mouse serum or saline to control for non-specific effects. Poly I-C (4 mg/kg, i.p.) or vehicle were administered 2 days later. Resorptions were assessed on day 13.5. RESULTS: Poly I-C significantly elevated resorption rates, and anti-NKR-P1 abolished this effect. Body weight was reduced in all rats treated with poly I-C, including NK-depleted rats. This indicates the ability of NK-depleted rats to respond to poly I-C, yet to refrain from the resorption-promoting effects of poly I-C. CONCLUSIONS: This study suggests a role for NK cells in mediating poly I-C-induced resorptions.     

Activation of microglia by aggregated beta-amyloid or lipopolysaccharide impairs MHC-II expression and renders them cytotoxic whereas IFN-gamma and IL-4 render them protective

'Protective autoimmunity' refers to a well-controlled anti-self response that helps the body resist neurodegeneration. The response is mediated by autoimmune T cells, which produce cytokines and growth factors. Using an in vitro assay of hippocampal slices, we show that the cytokines interferon-gamma and (especially) interleukin-4, characteristic of pro-inflammatory and anti-inflammatory T cells, respectively, can make microglia neuroprotective. Aggregated beta-amyloid, like bacterial cell wall-derived lipopolysaccharide, rendered the microglia cytotoxic. Cytotoxicity was correlated with a signal transduction pathway that down-regulates expression of class-II major histocompatibility proteins (MHC-II) through the MHC-II-transactivator and the invariant chain. Protection by interleukin-4 was attributed to down-regulation of tumor necrosis factor-alpha and up-regulation of insulin-like growth factor I. These findings suggest that beneficial or harmful expression of the local immune response in the damaged CNS depends on how microglia interpret the threat, and that a well-regulated T-cell-mediated response enables microglia to alleviate rather than exacerbate stressful situations in the CNS.     

Evaluation of a novel method for grading heart murmur intensity

OBJECTIVE: To determine if heart murmur intensity grading performance can be improved using the heart sounds as an internal reference. METHODS: Single-blind controlled trial of 100 medical students, residents, and pediatric attending physicians at a children's hospital. Groups of 1 to 3 participants were alternately assigned to intervention and control groups, reported their method of grading heart murmur intensity, and then graded the intensity of a random sample of 20 recorded murmurs on a 6-point scale. Before rating another random sample of 20 murmurs, the intervention group was taught a system that uses the heart sounds as an internal reference. Primary outcomes were change in accuracy (percentage correct), interrater agreement (kappa), and consistency (kappa). Subgroup analyses were performed by training level and heart murmur grade. RESULTS: Grading accuracy improved more in the intervention group than the control group (Delta improvement, 5%; 95% confidence interval [CI], -0.1%-10.0%]). This was most pronounced among attending physicians (Delta improvement, 11%; 95% CI, 0.4%-22%) and students (Delta improvement, 12%; 95% CI, 3%-20%) and for grade 2 murmurs (Delta improvement, 20%; 95% CI, 10%-31%). Relatively greater improvements in consistency were observed after the intervention for attending physicians (Delta improvement, 0.17; 95% CI, 0.01-0.32) and grades 2 (Delta improvement, 0.22; 95% CI, 0.09-0.36) and 3 murmurs (Delta improvement, 0.16; 95% CI, 0.05-0.28). CONCLUSIONS: A system that uses the heart sounds as an internal reference for grading heart murmur intensity quickly improves accuracy and consistency for some providers and specific murmurs.     

Inherited factor VII deficiency: identification of two novel mutations (A191V and T239P) in the catalytic domain

We describe here five F7 mutations found in four patients without bleeding history, despite constitutional coagulation Factor VII (FVII) deficiency. All five mutations are missense and affect the catalytic domain of FVII (A191T, A191V, T239P, R224Q and M298I). The A191V and T239P mutations are novel and were found in homozygous patients with no clinical bleeding tendency. The patient diagnosed with the A191V mutation had a phenotype corresponding to a moderate type 1 FVII deficiency (FVII:C 4%, FVII:Ag 5%). The T239P mutation was found in a patient with mild type 2 FVII deficiency (FVII:C 25%, FVII:Ag 95%). Novel mutations are both in close vicinity to the charge-stabilizing system of FVII. Modeling studies allow understanding in part the molecular basis for the loss of function.     

Obsessive-compulsive symptoms in patients with temporal lobe epilepsy

The goals of this work were to: (1) determine the prevalence of clinically significant obsessive-compulsive (OC) symptoms in patients with temporal lobe epilepsy (TLE), (2) characterize the differences in self-reported OC symptoms in patients with TLE and a normative control group, and (3) compare the severity of OC symptoms in right and left hemisphere TLE patients. Patients with TLE (n=30) were administered the Obsessive-Compulsive Inventory (OCI). As a group, patients with TLE had a higher prevalence of OC symptoms than the nonpatient normative sample. In addition, TLE patients exhibited elevated scores on all but 3 of the 16 OCI scales and subscales. There were no reliable differences in OC symptoms in patients with right versus left hemisphere seizure foci, although the right hemisphere patients tended to score higher on both scales of the OCI.