Oscillatory potentials in the retina: what do they reveal

This chapter is an overview of current knowledge on the oscillatory potentials (OPs) of the retina. The first section describes the characteristics of the OPs. The basic, adaptational, pharmacological and developmental characteristics of the OPs are different from the a- and b-waves, the major components of the electroretinogram (ERG). The OPs are most easily recorded in mesopic adaptational conditions and reflect rapid changes of adaptation. They represent photopic and scotopic processes, probably an interaction between cone and rod activity in the retina. The OPs are sensitive to disruption of inhibitory (dopamine, GABA-, and glycine-mediated) neuronal pathways and are not selectively affected by excitatory amino acids. The earlier OPs are associated with the on-components and the late OPs with the off-components in response to a brief stimulus of light. The postnatal appearance of the first oscillatory activity is preceded by the a- and b-waves. The earlier OPs appear postnatally prior to, and mature differently from, the later ones.

The second section deals with present views on the origin of the OPs. These views are developed from experimental studies with the vertebrate retina including the primate retina and clinical studies. Findings favor the conclusion that the OPs reflect neuronal synaptic activity in inhibitory feedback pathways initiated by the amacrines in the inner retina. The bipolar (or the interplexiform) cells are the probable generators of the OPs. Dopaminergic neurons, probably amacrines (or interplexiform cells), are involved in the generation of the OPs. The earlier OPs are generated in neurons related to the on-pathway of the retina and the later ones to the off-channel system. Peptidergic neurons may be indirectly involved as modulators. The individual OPs seem to represent the activation of several retinal generators. The earlier OPs are more dependent on an intact rod function and the later ones on an intact cone system. Thus, the OPs are good indicators of neuronal adaptive mechanisms in the retina and are probably the only post-synaptic neuronal components that can be recorded in the ERG except when structured stimuli are used.

The last section describes the usefulness of the oscillatory response as an instrument to study the postnatal development of neuronal adaptation of the retina. In this section clinical examples of the sensitivity of the OPs for revealing early disturbance in neuronal function in different retinal diseases such as pediatric, vascular and degenerative retinopathies are also given.     

Ultrasound in Sciatica

Investigation of the sagittal diameter of the spinal canal by ultrasound has shown a relative stenosis in patients with sciatica. In this study 12 patients who had recovered uneventfully after being operated on for herniated lumbar discs were found to have a broader spinal canal than 10 patients treated in the same way but still suffering from pain. Moreover, more difficulty was experienced investigating this latter group with the described “B-scan” technique. It is suggested that a preoperative ultrasound investigation would be able to indicate a narrow spinal canal and thereby reduce the number of disc operation failures.     

Three-Day Treatment of Acute Lower Urinary Tract Infections in Women

The aim of this study was to determine if a three-day treatment of lower urinary tract infection (UTI) is effective. 215 women with symptoms of lower UTI, seen in general practice, were randomly allocated to a double-blind study and given either amoxycillin 1000 mg twice a day for three days or trimethoprim 90 mg/sulphadiazine 410 mg (co-trimazine) 2 tablets initially, then one tablet twice daily for three days. 157 women (73%) had significant bacteriuria. Therapeutic efficacy was evaluated in 146 patients. One week after treatment had started, 88 % of the women in the amoxycillin group and 100% in the co-trimazine group were cured (p<0.01). After a follow-up period of four weeks, the cumulative relapse frequencies were 19% and 9% respectively. Adverse reactions were mild in most cases. Two patients, both on co-trimazine, had to discontinue treatment because of nausea and vomiting. Vulvovaginal irritation was more often reported by women treated with amoxycillin (n=8) than by those treated with co-trimazine (n = 1) (p<0.05). It is concluded that a three-day course of amoxycillin or co-trimazine in lower UTI is safe, causes few adverse reactions, is simple to administer and comfortable for the patient. Co-trimazine seems to be more effective than amoxycillin.     

Intracapsular pressure in transient synovitis of the hip

Fourteen consecutive children with symptoms of transient synovitis of the hip were examined with sonography regarding intracapsular effusion, with scintimetry regarding blood-flow in the proximal femoral epiphysis (PFE) and with intracapsular pressure recording and aspiration. All patients had an intracapsular effusion. Intracapsular pressure was found to depend on the position of the hip. The mean pressure with hips in extension and inward rotation was 22.6 kPa (170 mm Hg) whereas in 45 of flexion it was 2.3 kPa. In two cases scintimetry demonstrated reduced blood flow to the PFE; after aspiration, isotope uptake returned to normal, indicating that increased intracapsular pressure has a harmful effect on circulation to the PFE.

Children with transient synovitis should be treated with the hips in 45 of flexion to reduce intracapsular pressure. Forcing the hip in extension causes a risk of ischaemia of the PFE.     

Morale in the oldest old: the Umeå 85+ study

OBJECTIVE: to describe morale among the oldest old, and to investigate which social, functional and medical factors are associated with morale in this population. DESIGN: a cross-sectional study. SETTING: a population-based study in the municipality of Ume?, a city in Northern Sweden. SUBJECTS: half of the 85-year-old population, and the total population of 90-year-olds and > or = 95-year-olds (95-103) were asked to participate (n = 319) and 238 were interviewed. METHODS: structured interviews and assessments during home visits, interviews with relatives and caregivers and review of medical charts. The 17-item Philadelphia Geriatric Center Morale Scale (PGCMS) was used to measure morale. Participants were assessed with the Barthel Activities of Daily Living (ADL) Index, Geriatric Depression Scale (GDS-15), Mini-Mental State Examination (MMSE), Mini Nutritional Assessment (MNA), and a symptom questionnaire. Multiple regression analyses were conducted to find independent factors to explain the variation in the PGCMS score. RESULTS: eighty-four per cent (n = 199) of those interviewed answered the PGCMS. Three-quarters had middle range or high morale. GDS score, type of housing, previous stroke, loneliness and number of symptoms, adjusted for age group and sex, explained 49.3% of the variance of total PGCMS score. CONCLUSIONS: a large proportion of the oldest old had high morale. The most important factors for high morale were the absence of depressive symptoms, living in ordinary housing, having previously had a stroke and yet still living in ordinary housing, not feeling lonely and low number of symptoms. The PGCMS seems applicable in the evaluation of morale among the oldest old.     

Effect of a high-intensity functional exercise program on functional balance: preplanned subgroup analyses of a randomized controlled trial in residential care facilities

OBJECTIVES: To evaluate whether age, sex, depression, dementia disorder, nutritional status, or level of functional balance capacity influences the effect of a high‐intensity functional weight‐bearing exercise program on functional balance. DESIGN: Preplanned subgroup analyses of a randomized controlled trial. SETTING: Nine residential care facilities. PARTICIPANTS: One hundred ninety‐one people aged 65 to 100 dependent in activities of daily living and with Mini‐Mental State Examination scores of 10 or greater. INTERVENTION: A high‐intensity functional weight‐bearing exercise program or a control activity, each comprising 29 sessions over 3 months. MEASUREMENTS: Functional balance capacity was assessed blindly using the Berg Balance Scale (BBS) at baseline, 3 months, and 6 months. The BBS consists of 14 tasks, common in everyday life, such as standing up from sitting and, while standing, reaching forward or turning 360°. Interactions between allocation to activity group and each subgroup were evaluated according to the intention‐to‐treat principle. RESULTS: The subgroup analyses revealed no statistically significant interaction for age, sex, depression, dementia disorder, nutritional status, or level of functional balance capacity at 3 (P=.65, .65, .51, .78, .09, .67, respectively) or 6 (P=.69, .62, .20, .94, .48, .85, respectively) months. In addition, at 3 and 6 months there was no significant interaction for cognitive level (P=.28, .47, respectively) or number of depressive symptoms (P=.85, .49, respectively). CONCLUSION: Older age, female sex, depression, mild to moderate dementia syndrome, malnutrition, and severe physical impairment do not seem to have a negative effect on functional balance from a high‐intensity functional weight‐bearing exercise program. Consequently, people with these characteristics in residential care facilities should not be excluded from offers of rehabilitation including high‐intensity exercises.     

CRP, interleukin-6, secretory phospholipase A2 group IIA, and intercellular adhesion molecule-1 during the early phase of acute coronary syndromes and long-term follow-up

OBJECTIVES: The objectives of this study were to examine the time course of the inflammatory response in acute coronary syndromes (ACS) and to assess the markers of inflammation and their relation to disease severity. METHODS: We prospectively studied 134 patients with ACS who survived for at least 30 months. The patients were divided into four groups: acute myocardial infarction (MI) with (n=54) or without (n=46) ST-segment elevation and unstable angina with (n=14) or without (n=20) increased risk. Plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6), secretory phospholipase A2 group IIA (sPLA2-IIA), and intercellular adhesion molecule-1 (ICAM-1) were measured on days 1 and 4 and after 3 and 30 months. RESULTS: The highest levels of CRP and sPLA2-IIA were seen on day 4 but for IL-6 on day 1. These three markers, but not ICAM-1, were significantly related to disease severity, CKMB, and ejection fraction. Patients in Killip class II-IV had higher levels than those in Killip class I. The individual acute-phase responses correlated with marker levels at 3 and 30 months. ICAM-1 correlated with the development of congestive heart failure. CONCLUSIONS: In ACS there seems to be an individual predisposition to inflammatory response. Plasma IL-6 is the first marker to rise, while sPLA2-IIA and CRP peak later. All three markers, especially CRP, may discriminate between MI and non-MI. ICAM-1 seems to reflect other aspects of the inflammatory processes than the other markers. The results emphasize the complexity of the inflammatory response in ACS and stress the need for further studies involving multiple markers.     

Association between received treatment elements and satisfaction with care for patients with knee osteoarthritis seen in general practice in Denmark

ObjectiveWhile education, exercise, and weight reduction when indicated, are recommended first-line treatments for knee osteoarthritis patients, they remain poorly implemented in favour of pain killer treatment, imaging and referral to surgery. A reason could be that patients are more satisfied with receiving these adjunctive treatment elements. This study aimed to investigate the associations between the received elements of care and the patient’s satisfaction with the care for knee osteoarthritis in general practice.DesignCross-sectional study.SettingA Danish general practice.SubjectsAll consecutive patients ≥30 years of age who consulted the general practitioner (GP) with chronic knee complaints during 18 months and who replied to a mailed questionnaire (n = 136).Main outcome measuresThe questionnaire addressed patient’s knee-related quality of life, and overall satisfaction with care, as well as reception of seven types of information, which are known quality indicators. Information on reception of adjunctive treatment elements was obtained from electronic medical records.ResultsPatient satisfaction (versus neutrality/dissatisfaction) was positively associated with reception of information on: physical activity and exercise (relative risks [RR] 1.38, 95% bootstrap percentile interval [BPI] 1.02–4.33), and the relationship between weight and osteoarthritis (1.38, 1.01–4.41). No significant associations were found for the five remaining types of information and all the adjunctive treatment elements.ConclusionProviding information as education to patients with knee osteoarthritis as part of the treatment is positively associated with satisfaction with care.

KEY POINTS

• General practitioners worry about the doctor–patient relationship when addressing recommended lifestyle changes. However, this study revealed:
• •Patients in general practice with knee osteoarthritis are satisfied with care after having received information on lifestyle changes, such as exercise and the relationship between weight and osteoarthritis.
• •Patient satisfaction was not associated with the reception of adjunctive treatment elements for osteoarthritis.