Supratentorial ischemic stroke: more than an upper motor neuron disorder.

The primary goal of this study was to identify secondary functional changes in the peripheral motor units of the paretic upper extremity (UE) in patients with severe ischemic stroke and to determine how these changes develop during the first weeks after stroke. An inception cohort of 27 consecutive patients with an acute ischemic supratentorial stroke and an initial UE paralysis was compared with 10 healthy control subjects. The ulnar nerve was electrically stimulated proximal to the wrist and electromyographic recordings were obtained from the abductor digiti minimi muscle. Hemiparetic side mean values of the compound muscle action potential (CMAP) 1 and 3 weeks after stroke were compared with the nonparetic side and with CMAP values obtained from healthy control subjects. The mean CMAP amplitude in patients was significantly lower on the paretic side compared with the nonparetic side and with control subjects. Decrease in CMAP amplitude was observed in more than half of the stroke patients, sometimes as early as 4 days after stroke, and persisted in most cases. Whenever present, it was accompanied by absence of motor recovery at that specific time after stroke. Decreased CMAP amplitude in the abductor digiti minimi muscle can be seen already in the very acute phases after stroke unrelated to peripheral neuropathy, radiculopathy, or plexopathy, and it is accompanied by absence of UMN recovery. This knowledge is important for interpreting electrophysiological data in stroke patients.     

A short-term follow-up comparison of two trans-obturator tape procedures

The objective of the study was to compare the clinical outcomes at the short-term follow-ups of two novel transobturator mid-urethral sling procedures – the transobturator tape (TOT) procedure and the tension-free vaginal tape (TVT)-obturator procedure. The study cohort consisted two groups of 40 women with urodynamically proven stress urinary incontinence (SUI). The patients in one group underwent the TOT procedure, performed according to Delorme (Prog Urol 11:1306–1313, 2001); those in the second group underwent the TVT-obturator operation, performed according to de Leval (Eur Urol 44:724–730, 2003). Intra-operative diagnostic cystoscopy was not performed with either the TVT-obturator or the TOT procedures. The average follow-up was 12 months. The two patient groups were similar in terms of demographic and therapeutic criteria, except for patient age, which was significantly younger in the TVT-obturator group. Previously reported TVT-related operative complications, such as bladder penetration, intra-operative bleeding, field infection and post-operative pelvic floor relaxation, were not observed in patients of either group. Bowel and urethral injuries were also not recorded. The therapeutic failure rates were 10% for the TOT procedure and 5% for the TVT-obturator procedure. Urinary frequency and urgency post-operatively were reported in 25% of the TOT patients and 19% of the TVT-obturator patients, pelvic or vaginal pain affected 10% of the TOT and 5% of the TVT-obturator patients, while post-operative voiding difficulty was experienced by 12.5% of the TOT and 7.5% of the TVT-obturator patients. None of the above-mentioned differences between the two patient groups were of statistical significance. The TVT-obturator and TOT procedures, both minimally invasive, novel, mid-urethral sling procedures, seem to be safe, easy-to-perform and effective in treating female SUI. The patients of both study groups suffered less intra- and post-operative surgical complications than previously been reported in connection with the TVT operation. The TVT-obturator patients had fewer therapeutic failures, less post-operative urinary frequency and urgency, less pelvic pain and less voiding difficulty. All of these findings, however, had no statistical significance; consequently, long-term comparative data collection will be required before solid conclusions can be drawn on the superiority of either of these two operative techniques.     

Effect of daily variation in weather and sleep on seasonal affective disorder

Analysis of daily self-ratings of energy for 10 patients diagnosed with seasonal affective disorder (SAD) revealed statistically significant seasonal patterns in eight patients (with all patients showing the most energy in the summer and the least energy in the winter). When weather was controlled for, the seasonal patterns in energy persisted in seven of the eight patients. In a lesser number of subjects (four), there were significant effects of weather after controlling for season; however, when the effects of weather on energy were examined separately for each season, 8 of the 10 subjects were found to be influenced by weather in at least one season. Daily sleep data showed statistically significant seasonal patterns in all 10 patients (with 6 subjects showing maximum sleep in winter and 4 in summer). As for the relationship between energy and sleep, a loss of energy appeared to predict longer sleep on that night and the next night (7 of 10 patients), whereas there was no evidence that prolonged sleep influenced energy on the following and subsequent days.     

Kienb?ck's disease

Kienb?ck's disease is an isolated disorder of the lunate resulting from vascular compromise to the bone. The symptoms include wrist pain, limited range of motion, and decreased grip strength. The diagnosis is made from characteristic changes seen in the lunate on radiograms of the wrist. The severity of the disease can be categorized by staging the degree of involvement. This is helpful in guiding the practitioner through the maze of treatment options. Initial treatment of Kienb?ck's disease is conservative and includes immobilization, analgesics, and/or anti-inflammatory medication. If symptoms are not relieved, then based on the degree of involvement, several surgical options exist that will provide a successful result. These include autogenous tendon replacement arthroplasty, revascularization, radial shortening, ulnar lengthening, limited intercarpal arthrodesis, and silicone replacement arthroplasty. Salvage procedures for Kienb?ck's disease include wrist denervation, wrist arthrodesis, and proximal-row carpectomy. Currently, we prefer immobilization for treatment of stage I Kienb?ck's disease. For stage II, a revascularization procedure may be attempted or ulnar lengthening/radial shortening done, particularly if there is significant negative ulnar variance. In stage III, replacement arthroplasty and/or limited intercarpal arthrodesis is our treatment of choice, and for stage IV, one of the salvage procedures is indicated.     

Reflex sympathetic dystrophy of the left hand and motor impairments of the unaffected right hand: impaired central motor processing?

OBJECTIVE: To test whether central motor processing can be impaired in chronic reflex sympathetic dystrophy (RSD). DESIGN: Experimental 2-group analysis. SETTING: Tertiary care center in the Netherlands. PARTICIPANTS: Five patients with stage 3 RSD of the left forearm, free of symptoms and complaints in the right forearm; and 10 healthy control subjects. INTERVENTION: On a digitizer, RSD patients and controls had to draw 3 sequences of graphemes of different complexity with their (unaffected) dominant right hand. The drawing tracks were segmented in time periods between points of velocity minima of the pen tip. MAIN OUTCOME MEASURES: Mean velocity, coefficients of variation of both length and movement time per segment, and mean intersegmental pausing time were calculated for each sequence. RESULTS: A repeated-measures analysis of variance by using the multivariate method yielded a 35% lower mean velocity (F(1,13) = 5.83, P =.031), a 110% larger segment length variability (F(1,13) = 9.72, P =.008) and a 60% larger variability of movement time per segment (F(1,13) = 5.78, P =.032) in RSD patients. No group difference was found for intersegmental pausing time or any interaction effect with the type of task. CONCLUSION: Patients with chronic RSD have a normal ability to preprogram sequential movements of their unaffected hand; but with impaired temporospatial coding and movement execution. We concluded that cortical mechanisms may be involved in motor impairments in patients with chronic RSD.     

Acute effect of norfenefrine on the urethral pressure profile in females with genuine stress incontinence

To study the acute effect of norfenefrine, given orally in aqueous solution, on the urethral closure function, profilometry was performed before and after administration of placebo and increasing doses of norfenefrine in 6 females with genuine stress incontinence. A weak increase in urethral pressure was observed after administration of 90 mg of norfenefrine. No changes in heart rate and blood pressure occurred. The results indicate that the direct sympathomimetic effect of norfenefrine is weak. It is suggested that norfenefrine mainly acts via indirect mechanisms.     

Bell's palsy associated with IFN-alpha and ribavirin therapy for hepatitis C virus infection.

First-line therapy for hepatitis C virus (HCV) infection comprises interferon-alpha (IFN-alpha) and ribavirin for 6 or 12 months. Mild complications of therapy are common, but more serious complications are rare. Three patients with chronic HCV infection, acquired through injecting drug use, developed idiopathic facial paralysis (Bell's palsy) during therapy, with spontaneous resolution after withdrawal of treatment. Large-scale cohort studies reveal that IFNs are associated rarely with neurologic complications, and only one previous report has linked IFN-alpha therapy and Bell's palsy. We postulate that IFN-alpha therapy led to a breakdown of peripheral tolerance to myelin sheath antigens, leading to neuropathy, just as IFN-alpha therapy can cause autoimmune thyroiditis through breakdown of tolerance to native thyroid antigens.     

Acute Osteomyelitis of the Pubic Bone Following Pelvic Surgery

Primary osteomyelitis of the pubic bone has not been recorded previously. The authors present a case of this unusual entity.