Late whiplash syndrome: correlation of brain SPECT with neuropsychological tests and P300 event-related potential

BACKGROUND: The acceleration forces infringing the cervical spine in whiplash injury are frequently associated with multiple cerebral symptoms. The purpose of this study was to determine whether there is a correlation between cerebral perfusion findings, P300 recording (an electrophysiologic marker of cognitive ability), and neuropsychological tests in patients with whiplash injury. METHODS: Twenty patients with chronic whiplash injury underwent extensive clinical evaluation and neuropsychological testing. A brain single-photon emission computed tomography (SPECT) study using 99mTc-HMPAO was performed in all patients within 24 hours of neuropsychological evaluation. P300 event-related potentials were performed in 15 patients and in 9 normal volunteers. RESULTS: Thirteen of 20 patients had brain perfusion abnormalities on the SPECT studies, in one or more regions. Eight of 15 patients had abnormal P300 studies. Seven of eight patients with abnormal P300 had also an abnormal SPECT study. Seven of 15 patients had normal P300 results, 6 of them with a normal SPECT and 1 with SPECT abnormalities. There was no significant correlation between the SPECT findings or the P300 results and the scores of attention and working memory. There was, however, close agreement between the SPECT and P300. CONCLUSION: SPECT perfusion abnormalities in patients with chronic whiplash syndrome correlate well with P300 recording. The combination of these studies with neurocognitive and neurobehavioral tests may be useful in identifying a subgroup of patients having organic brain lesions.     

Perianal Crohn disease: a new scoring system to evaluate and predict outcome of surgical intervention

BACKGROUND: Conventional Crohn disease activity indices do not reflect perianal disease activity or allow prognostic implications from surgery. HYPOTHESIS: A new scoring system, based on the patient's disease history and physical examination findings, will allow more accurate use of surgical intervention for perianal Crohn disease. METHODS: A standardized scoring questionnaire was developed and applied to a consecutive group of patients before surgical treatment of perianal Crohn disease. The scoring system included abscess, fistula, ulcer and fissure, stenosis, incontinence, and concomitant disease. Weighted factors included acuity vs chronicity, de novo vs recurrent disease, and concomitant intestinal disease. The scoring system was validated against the surgical outcome, which was classified as poor, satisfactory, or good. RESULTS: Twenty-eight patients with Crohn disease who underwent 33 surgical procedures had a mean score of 16.5 (range, 3-37; possible range, 0-55). Using the Spearman nonparametric correlation test, the scoring system was accurate in predicting the outcome of surgical intervention (correlation coefficient, 0.78, 95% confidence interval, 0.57-0.89; P<.001) at mean follow-up of 20.8 months (range, 6-40 months). Correlation was further validated using a linear regression model (r = 0.75, slope best-fit value, 3.8; 95% confidence interval, 2.46-5.14; P<.001). All patients with a score of 10 or less had a good outcome, whereas all those with a score of 20 or greater had a poor outcome. CONCLUSIONS: The proposed scoring system correlated well with the short-term outcome of surgical intervention in patients with perianal Crohn disease and allowed prediction of surgical success. Ultimately, it may be possible to alter therapy based on preoperative prediction of the expected postoperative outcome.     

Sleep, sleepiness, and behavior problems in children with headache

The purpose of this study was to assess sleep, daytime sleepiness, and behavior problems in children suffering from headaches and in controls, with a special focus on the role of gender. A clinical group of 28 children with persistent headache complaints and a control group of 108 healthy children were included. Sleep was assessed by actigraphy and diaries. Behavior problems were assessed by parental reports. In comparison with the control group, the sleep quality of the clinical group was poorer and they complained more about excessive daytime sleepiness. Children suffering from headache showed higher levels of internalizing behavior problems. Gender was found to be a moderating factor for the relationships between headache and sleep. Compared with control girls, girls suffering from headaches had poorer sleep quality, whereas the opposite was true for the boys. The results highlight the importance of assessing sleep, daytime sleepiness, and psychologic adjustment in children complaining about headaches as an integral part of their routine assessment.     

Does preoperative symptom classification impact prognosis in patients with clinically localized upper-tract urothelial carcinoma managed by radical nephroureterectomy?

ObjectivesTo evaluate if preoperative symptom classification could refine prediction of outcomes for patients with clinically localized upper-tract urothelial carcinoma (UTUC) managed by radical nephroureterectomy (RNU).MethodsData on 654 patients with localized UTUC who underwent RNU were reviewed. Preoperative symptoms were classified as incidental (S1), local (S2), and systemic (S3). Clinical and pathologic data were compared between the cohorts. Kaplan-Meier analyses and Cox proportional hazard modeling were used to determine recurrence-free and cancer-specific survival amongst the symptom cohorts.ResultsSymptom classification was S1 in 213 (33%) patients, S2 in 402 (61%), and S3 in 39 (6%). S3 symptoms were associated with advanced pathology, including higher stage, grade, and lymph node (LN) positivity. Five and 10-year recurrence-free and cancer-specific survival estimates were similar for patients with S1 and S2 symptoms (P = 0.75 and 0.58, respectively), but was worse for patients with S3 symptoms (P < 0.001 for both). On multivariate analysis adjusting for final pathologic stage, grade, and LN status, S3 symptoms were not an independent predictor of recurrence (HR 1.44, P = 0.19) or death due to disease (HR 1.66, P = 0.07). Addition of symptom classification, however, increased the accuracy of a model consisting of stage, grade, and LNs for prediction of recurrence-free and cancer-specific survival by 1.4% and 1.3%, respectively (P < 0.001 for both).ConclusionsLocal symptoms do not confer worse prognosis compared with patients with incidentally detected UTUC. However, systemic symptoms are associated with worse outcomes despite apparently effective RNU. Patients with systemic symptoms may harbor micrometastatic disease and could potentially benefit from a more rigorous metastatic evaluation or perioperative chemotherapy regimens.     

Normal urinary calcium/creatinine ratios in African-American and Caucasian children

A random urine calcium/creatinine ratio (UCa/Cr) is of practical use in screening for hypercalciuria. However, due to worldwide variations, reference values for the pediatric population are not yet well established. Furthermore, no study has been conducted to establish normal UCa/Cr values in young African-American (AA) children. It has also been previously reported that an elevated UCa/Cr is related to a high urine Na/K ratio (UNa/K). The objectives of the present study were: (1) to set normal values of random UCa/Cr by age and race in the pediatric population of Metropolitan Kansas City, (2) to identify potential racial differences in UCa/Cr between Caucasian (CS) and AA children, and (3) to determine the relationship between UCa/Cr and UNa/K in healthy children.A total of 368 healthy children of both genders were enrolled in the study. They were divided into four age groups as follows: (1) <7 months, (2) 8–18 months, (3) 19 months to 6 years, and (4) 7–16 years. Each group was subdivided into AA and CS. A non-fasting random urine specimen from each subject was analyzed for Ca, Na, K and creatinine.The median UCa/Cr values for AA were: (1) 0.13, (2) 0.09, (3) 0.06, and (4) 0.04 and for CS they were (1) 0.26, (2) 0.11, (3) 0.10, and (4) 0.09. The data showed a strong inverse relationship between UCa/Cr and age, the youngest children demonstrating the highest UCa/Cr. In each age group, UCa/Cr in CS exceeded the corresponding value in AA. The age-dependent 95th percentiles of UCa/Cr values for CS were (1) 0.70, (2) 0.50, (3) 0.28, and (4) 0.20 and for AA they were (1) 0.38 and (3) 0.24. Due to outliers, the 95th percentile could not be established for the other two AA subgroups. The relationship between UCa/Cr and UNa/K was found to be extremely weak in both AA (r ² =0.00005) and CS (r ² =0.02). On the other hand, a strong linear correlation was observed between UNa/K and age (CS r ² =0.23, P<0.001, AA r ² =0.19, P<0.001), explaining in part the lack of correlation between UNa/K and UCa/Cr.We conclude that the child’s age, ethnicity and geographic location should be taken into consideration when assessing UCa/Cr ratio. Contrary to what has previously been reported in hypercalciuric children, no significant relationship was found between UCa/Cr and UNa/K in healthy children. Received: 7 June 2000 / Revised: 21 September 2000 / Accepted: 23 September 2000     

Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot

Objectives

Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury.

Methods

This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years).

Results

Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later.

Conclusions

This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient’s functional activity and quality of life.     

Reversal of hypercalcemic acute kidney injury by treatment with intravenous bisphosphonates

We present the details of three children with hypercalcemia-induced acute kidney injury (AKI). After traditional therapy with fluids, loop diuretics, steroids and calcitonin had failed to correct the hypercalcemia, they were given treatment with low doses of intravenous (i.v.) pamidronate, which resulted in normalization of serum calcium and kidney function. In one child Doppler renal ultrasound revealed dampened arterial blood flow, which resolved with normalization of serum calcium. On the basis of cumulative data and our experience, we suggest that i.v. application of bisphosphonates be moved from the second to the first line of treatment of hypercalcemic AKI.