Bimanual Recoupling by Visual Cueing in Callosal Disconnection

Abstract

The cerebral control of bimanual movements is not completely understood. We investigated a 59-year-old, right-handed man who presented with an acute bimanual coordination deficit. Magnetic resonance imaging showed a lesion involving the entire corpus callosum, which was found on stereotactic biopsy to be an ischemic infarct. Paired-pulse transcranial magnetic stimulation indicated that the patient had a lack of interhemispheric inhibition, while intracortical inhibition in motor cortex of either side was normal. Functional magnetic resonance imaging showed activation of the left SMA, the bilateral motor cortex and anterior cerebellum during spontaneous bimanual thumb-index oppositions, which were uncoupled as evident from simultaneous electromyographic recordings. In contrast, when the bimanual thumb-index oppositions were cued by a visual stimulus, the movements of both hands were tightly correlated. This synchronized activity was accompanied by additional activations bilateral in lateral occipital cortex, dorsal premotor cortex and cerebellum. The data suggest that the visually cued movements of both hands were recoupled by action of a bihemispheric motor network.     

Predicting the in‐patient outcomes of acute medical admissions from the nursing home: The experience of St James's Hospital,Dublin, 2002–2010

Aim: To identify predictors of negative in‐patient outcomes (prolonged hospital stay and death) in nursing home (NH) residents admitted to the hospital as medical emergencies. Methods: This was a retrospective patient series set at St James's Hospital (Dublin, Ireland). The participants were all NH patients requiring acute medical admission under the on‐call medical team between 1 January 2002 and 31 December 2010. Patient characteristics on admission, such as demographics, comorbidity level, major diagnostic categories, vital signs and laboratory profile, were measured. The outcomes of the study were prolonged hospital stay (≥30 days) and in‐hospital mortality. The characteristics of NH patients were compared with those of non‐NH patients aged ≥65 years. Multivariate analyses were based on generalized estimating equations and classification trees. Results: There were 55 763 acute medical admissions over the period, of which 1938 (3.5%) were from NH. As compared with non‐NH patients aged ≥65 years, NH patients had greater acute illness severity. NH patients had a median length of stay of 7 days, and 17% had a prolonged admission. Their overall mortality rate was 23%. However, the classification analysis showed substantial patient heterogeneity; the subgroup with the highest mortality (54%, n = 100) had positive serum troponin and a respiratory major diagnosis. The lowest mortality rate (4%) was seen in those without positive troponin, urea of 12 mmol/L or less, and albumin of more than 37 mg/L (n = 226). Conclusions: Simple serum markers, such as troponin, urea and albumin, might predict mortality in medically admitted NH patients. This might help health‐care practitioners to anticipate their clinical course at an early stage. Geriatr Gerontol Int 2012; ??: ??–??.     

Guided self-help for binge eating/purging anorexia nervosa before inpatient treatment

Abstract

The goal of this study was to develop a cognitive–behavioral self-help manual for anorexia nervosa. Patients diagnosed with anorexia nervosa (N=102), binge eating/purging type (AN-B/P), were consecutively assigned to one of two conditions: 6-week manualized guided self-help or a wait-list control. All patients thereafter received inpatient treatment in a hospital for behavioral medicine. The primary outcome variable was the number of days in inpatient treatment. Secondary outcome variables were measures of psychopathology. Results showed that duration of inpatient treatment was significantly shorter (by 5.2 days) among participants receiving guided self-help. Body image, slimness ideal, general psychopathology, and some bulimic symptoms improved significantly during self-help. The authors conclude that, to increase effects of therapist-guided self-help in AN-B/P, additional variants of a self-help manual should be tried in different therapeutic settings.     

Role of Cytochrome P450 3A4 and 1A2 Phenotyping in Patients with Advanced Non‐small‐Cell Lung Cancer Receiving Erlotinib Treatment

Erlotinib is metabolized by cytochrome p450 (CYP) 3A and CYP1A. This study assessed CYP3A4 (midazolam) and CYP1A2 (caffeine) phenotyping in plasma and dried blood spots (DBS) for predicting the pharmacokinetics and toxicity of erlotinib in 36 patients with advanced NSCLC. On day 1, erlotinib 150 mg OD was initiated, and the two oral probe drugs midazolam (2 mg) and caffeine (100 mg) were added on day 1. Plasma and DBS were collected for erlotinib, OSI‐420 and probe drugs for up to 6 hr on day 1 and 2‐weekly up to week 10. Probe drugs, erlotinib and OSI‐420 were analysed using LC‐MS‐MS, and PK data were processed using population modelling. A high correlation was found between plasma and DBS concentrations for erlotinib (R² = 0.960, p < 0.0001), OSI‐420 (R² = 0.971, p < 0.0001), midazolam (R² = 0.995, p < 0.0001) and caffeine (R² = 0.968, p < 0.0001). Apparent oral caffeine clearance was significantly correlated with erlotinib clearance (R² = 0.33, p = 0.048), while midazolam clearance was not (R² = ?0.09, p = 0.596). Erlotinib clearance was lower in patients experiencing grade 2 or 3 rash as compared to patients experiencing grade 0 or 1 rash (3.15 versus 3.93 L/hr, p = 0.086 for Student's t‐test). The results suggest that probe drug phenotyping is unlikely to substitute therapeutic drug monitoring of erlotinib in patients with advanced NSCLC, but erlotinib PK sampling from DBS may replace more invasive venous sampling and facilitate TDM in patients with cancer.     

Recreational marijuana use is not associated with worse outcomes after renal transplantation

As marijuana (MJ) legalization is increasing, kidney transplant programs must develop listing criteria for marijuana users. However, no data exist on the effect of MJ on kidney allograft outcomes, and there is no consensus on whether MJ use should be a contraindication to transplantation. We retrospectively reviewed 1225 kidney recipients from 2008 to 2013. Marijuana use was defined by positive urine toxicology screen and/or self‐reported recent use. The primary outcome was death at 1 year or graft failure (defined as GFR<20 mL/min/1.73 m²). The secondary outcome was graft function at 1 year. Using logistic regression analyses, we compared these outcomes between MJ users and non‐users. Marijuana use was not associated with worse primary outcomes by unadjusted (odds ratio 1.07, 95% CI 0.45–2.57, P=.87) or adjusted (odds ratio 0.79, 95% CI 0.28–2.28, P=.67) analysis. Ninety‐two percent of grafts functioned at 1 year. Among these, the mean creatinine (1.52, 95% CI 1.39–1.69 vs 1.46, 95% CI 1.42–1.49; P=.38) and MDRD GFR (50.7, 95% CI 45.6–56.5 vs 49.5, 95% CI 48.3–50.7; P=.65) were similar between groups. Isolated recreational MJ use is not associated with poorer patient or kidney allograft outcomes at 1 year. Therefore, recreational MJ use should not necessarily be considered a contraindication to kidney transplantation.     

Nerve growth factor in serum is a marker of the stage of alcohol disease

Long-term alcohol abuse has deleterious effects on the peripheral and central nervous system. Nerve growth factor (NGF) is a pleiotropic neurotrophic protein involved in development, maintenance of function and regeneration of nerve cells. We examined patients in different stages of alcohol disease and measured their NGF serum concentrations based on the hypothesis that these reflect the state of disease. We examined 57 patients suffering from alcohol-dependence for more than 2 years (DSM IV) on day 8 of a qualified withdrawal, 18 patients with Korsakoff's syndrome and 40 healthy controls. In addition to clinical examination, careful history taking and a standard neuropsychological test battery, serum NGF concentrations were measured by a highly sensitive enzyme-immunoassay. Of the 57 patients 9 had suffered from severe withdrawal delirium in the past, other clinical parameters were alike. Cognitive test performance did not differ from the control group. Mean NGF levels of controls amounted to 42.1pg/ml (S.D. 68.0); mean levels of patients with alcohol dependence were raised significantly to 401.5pg/ml (S.D. 932.6) without delirium in the past and even further to 3292.5pg/ml (S.D. 4879.6) with former withdrawal delirium. By contrast, patients with persistent amnestic disorder (Korsakoff's syndrome) showed values identical to the controls. NGF serum levels were significantly elevated in alcohol-dependent patients, more so in those with prior delirium. Their cognitive tests being normal, this possibly reflects the activity of NGF as an endogenous repair mechanism for damaged neurons. In accordance with this hypothesis, NGF values are "normal" in patients with persistent alcohol-related cognitive decline.