Predicting caregiver burden in general veterinary clients: Contribution of companion animal clinical signs and problem behaviors.

Caregiver burden, found in many clients with a chronically or terminally ill companion animal, has been linked to poorer psychosocial function in the client and greater utilization of non-billable veterinary services. To reduce client caregiver burden, its determinants must first be identified. This study examined if companion animal clinical signs and problem behaviors predict veterinary client burden within broader client- and patient-based risk factor models. Data were collected in two phases. Phase 1 included 238 companion animal owners, including those with a sick companion animal (n=119) and matched healthy controls (n=119) recruited online. Phase 2 was comprised of 602 small animal general veterinary hospital clients (n=95 with a sick dog or cat). Participants completed cross-sectional online assessments of caregiver burden, psychosocial resources (social support, active coping, self-mastery), and an item pool of companion animal clinical signs and problem behaviors. Several signs/behaviors correlated with burden, most prominently: weakness, appearing sad/depressed or anxious, appearing to have pain/discomfort, change in personality, frequent urination, and excessive sleeping/lethargy. Within patient-based risk factors, caregiver burden was predicted by frequency of the companion animal's signs/behaviors (P<.01). Within client-based factors, potentially modifiable factors of client reaction to the animal's signs/behaviors (P=.01), and client sense of control (P<.04) predicted burden. Understanding burden may enhance veterinarian-client communication, and is important due to potential downstream effects of client burden, such as higher workload for the veterinarian. Supporting the client's sense of control may help alleviate burden when amelioration of the companion animal's presentation is not feasible.

Doxycycline and intracranial hypertension.

The authors report seven patients from six neuro-ophthalmology referral centers who developed pseudo-tumor cerebri during treatment with doxycycline. All four female patients and one of three male patients were obese. Vision was minimally affected in most patients, but two had substantial visual acuity or visual field loss at presentation. Discontinuation of doxycycline, with or without additional intracranial pressure-lowering agents, yielded improvement, but permanent visual acuity or visual field loss occurred in five patients.

Optic perineuritis: clinical and radiographic features.

BACKGROUND: Optic perineuritis is an uncommon variety of orbital inflammatory disease that is distinct from demyelinating optic neuritis. OBJECTIVE: To describe the clinical and radiographic features of idiopathic optic perineuritis, with particular emphasis on those features that help to distinguish this condition from optic neuritis. METHODS: We reviewed the medical records of 14 patients with optic perineuritis who were seen in 2 neuro-ophthalmology clinics. RESULTS: Patients ranged in age from 24 to 60 years; 5 were older than 50 years. All patients had visual loss, eye pain, or both. The visual acuity was 20/20 or better in 8 of the 15 eyes. The results of visual field testing were normal in 2 eyes, and a paracentral scotoma or an arcuate defect was seen in 7. Magnetic resonance imaging scans demonstrated circumferential enhancement around the optic nerve, sometimes with intraorbital extension. Response to corticosteroids was dramatic; however, 4 patients had a relapse with lowering of the dose. CONCLUSIONS: In contrast to those with optic neuritis, patients with optic perineuritis are often older at onset and are more likely to show sparing of central vision. Magnetic resonance imaging scans demonstrate enhancement around, rather than within, the optic nerve. Response to corticosteroids is more dramatic than in patients with optic neuritis, and patients are more likely to experience recurrence after stopping treatment.

Duration of positive urine for cocaine metabolite after ophthalmic administration: implications for testing patients with suspected Horner syndrome using ophthalmic cocaine.

PURPOSE: To determine the duration of positive urine for benzoylecgonine, the major metabolite excreted in the urine, after topical ophthalmic administration of cocaine as one would perform for testing the presence of Horner syndrome. METHODS: Two drops of cocaine 10% were applied to each eye of 50 normal subjects. Urine samples were collected 4 to 6, 24, 48, 72, and 96 hours later. Each sample was assayed for benzoylecgonine using a screening competitive enzyme donor immunoassay followed by a highly specific and sensitive confirmatory gas chromatography-mass spectrometry assay. We employed assays and cutoff levels that fulfilled guidelines required by the Substance Abuse and Mental Health Services of the United States Department of Health and Human Services to mimic measures that exist for federal workplace drug testing. RESULTS: Of the 50 subjects, there were 25 women and 25 men, ranging in age from 19 to 59 years (median age, 40 years). Positive screening samples were obtained in 47 of 50 subjects (94%) 4 to 6 hours, 35 of 50 (70%) 24 hours, and 1 of 50 (2%) 48 hours after topical application of cocaine. None of the samples tested positive at 72 hours or beyond. Using the confirmatory assay's cutoff as the gold standard for a positive test, the sensitivity of the screening assay was 96% 4 to 6 hours, 90% 24 hours, and 14% 48 hours after topical application. Urine benzoylecgonine concentration was negatively correlated with body mass index and positively correlated with urine creatinine concentration. CONCLUSIONS: Patients should be informed that their urine may test positive for cocaine, if assayed according to US federal guidelines and using the protocol employed in this study, up to 2 days after undergoing testing for Horner syndrome.

Retinal anti-bipolar cell antibodies in a patient with paraneoplastic retinopathy and colon carcinoma.

PURPOSE: To describe clinical, electrophysiologic, and immunologic features of a unique paraneoplastic retinopathy with characteristics of cancer-associated and melanoma-associated retinopathy. METHODS: Serial assessment of clinical visual function, electroretinography, and assays of anti-retinal antibodies. RESULTS: A 51-year-old woman with progressive visual glare for 1 year had normal visual acuity and color vision, paracentral scotomas, and a normal-appearing retina. Electroretinography revealed no responses of the right eye and attenuated responses of the left eye, especially those recorded under scotopic conditions. Anti-bipolar antibodies were detected. Subsequent evaluation uncovered adenocarcinoma of the colon. Several months after resection of the tumor and chemotherapy, no evidence existed of cancer or anti-bipolar cell antibodies, and electroretinography responses were markedly improved. CONCLUSION: The presence of anti-bipolar cell antibodies in a patient with retinal dysfunction is not specific of melanoma-associated retinopathy. Effective treatment of cancer may result in elimination of associated anti-retinal antibodies and improved retinal function.

Comparison of clinical associations of patients with vasculopathic and idiopathic downbeat nystagmus.

OBJECTIVES: To perform a pilot study comparing age and vascular risk factors of patients with vasculopathic and idiopathic downbeat nystagmus (DBN). MATERIALS AND METHODS: We reviewed the case records of 57 patients with DBN evaluated between 1987 and 1999, and classified each patient into three groups: vasculopathic, idiopathic, and other known causes. We then compared age and five weighted established stroke risk factors in patients with vasculopathic and idiopathic DBN. RESULTS: Of ten idiopathic cases, there were seven women and three men, ranging in age from 31 to 90 years (median, 79 years). Of the nine vasculopathic cases, there were seven women and two men, ranging in age from 50 to 86 years (median, 80 years). Using the Mann-Whitney U test, there was no significant difference between the two groups in terms of age (p = 0.84) or vascular risk-factor profile (p = 0.24). CONCLUSIONS: The lack of significant difference between the two groups for age and vascular risk factors supports the hypothesis that some idiopathic cases of DBN may be caused by strategically located and radiographically occult cerebral infarctions.

Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass.

The causes of ophthalmoplegia in 24 consecutive patients with neurologically isolated, relative pupil-sparing third nerve palsy included infarction in 10 patients, compression by tumors or aneurysms in 10 patients, and miscellaneous disorders in four patients. There was no significant difference in the proportion of patients with pain, degree of external ophthalmoplegia, or degree of internal ophthalmoplegia between the groups with infarction or mass lesions. Therefore, screening for mass lesions using neuroimaging is indicated in patients with this presentation of third nerve palsy.

Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations.

OBJECTIVES: To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. METHODS: Retrospective survey of patients with divergence insufficiency. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Long-term follow-up and clinical features of the 2 groups were compared. RESULTS: Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. None of these patients developed signs of an underlying neurologic disorder during follow-up. Of the 15 patients with secondary divergence insufficiency, an underlying neurologic or systemic disorder was either known or initially suspected in all based on the initial history and physical examination. Divergence fusion amplitudes were significantly larger in patients with secondary divergence insufficiency compared with those with primary divergence insufficiency, although there was considerable overlap of values between the 2 groups. CONCLUSIONS: Primary divergence insufficiency is generally a benign condition. Many affected patients experience spontaneous resolution of double vision within several months. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Arch Ophthalmol. 2000;118:1237-1241

Dysthyroid orbitopathy.

Dysthyroid orbitopathy (DO) is an autoimmune disorder usually associated with Graves' disease. The extra-ocular muscles are the target of the autoimmune attack. As a result, they become enlarged, producing restrictive ophthalmoplegia and proptosis. Other cardinal signs of DO include upper eyelid retraction and lag, conjunctival injection and chemosis, and periorbital edema. Visual loss may occur if the enlarged extra-ocular muscles compress the optic nerve in the orbital apex. These cardinal signs may mimic neurological conditions, including Parinaud's syndrome, sixth nerve palsy, carotid-cavernous fistula, and spheno-orbital meningioma. Treatment is directed at the cardinal signs and is largely palliative. Under certain clinical conditions, judicious use of corticosteroids, radiation therapy, or surgery designed to decompress the orbit, correct strabismus, or restore normal lid position may help to restore visual function.

Symptomatic compression of the optic nerve by the carotid artery: clinical profile of 18 patients with 24 affected eyes identified by magnetic resonance imaging.

OBJECTIVE: To characterize the clinical features and course of patients with magnetic resonance imaging (MRI)-defined optic nerve compression by the supraclinoid carotid artery. DESIGN: Retrospective, observational case series. PARTICIPANTS: Eighteen patients with 24 affected eyes were identified by reviewing case records from the author's referral-based neuro-ophthalmology practice. Predetermined inclusion and exclusion criteria were applied to potential participants. MAIN OUTCOME MEASURES: The following variables were abstracted from the medical record: age, gender, presenting symptoms, past medical problems, visual acuity, color vision, visual field, pupillary reactions, optic disc appearance, other neurologic signs, and previously documented and follow-up examinations. RESULTS: There were eight women and ten men ranging in age from 28 to 86 years (median age, 72 years) at the time of diagnosis. Ten (56%) of 18 patients had hypertension. Twelve patients had unilateral optic neuropathy, whereas 6 patients had bilateral optic neuropathy. One patient presented with subacute superior orbital fissure syndrome due to mass effect of a dolichoectatic carotid artery. Another patient had oculomotor nerve palsy with signs of aberrant regeneration due to intracavernous mass effect of a dolichoectatic carotid artery. One patient had a bitemporal hemianopia associated with bilateral compression of the immediate prechiasmatic optic nerves by dolichoectatic carotid arteries. The predominant pattern of visual field loss in most patients reflected nerve fiber bundle injury. A central scotoma or absolute central visual field loss was noted in only 6 (25%) of 24 affected eyes. Most patients demonstrated saucerlike excavation of the optic disc. Progression of visual acuity loss occurred at a relatively slow rate. CONCLUSIONS: Although uncommon, intracranial compression of the optic nerve by the carotid artery should be considered in a patient with unexplained or progressive unilateral or bilateral optic neuropathy. This entity can be diagnosed using clinical skills to exclude more common causes of optic nerve injury and coronal-oriented MRI to confirm anatomic compression of the symptomatic optic nerve. Although many affected patients have excavation of the optic disc and nerve fiber bundle visual field defects, most have additional signs atypical for glaucoma, minimizing the potential for diagnostic confusion between the two disorders.

Gliomas of the anterior visual pathways.

Gliomas of the anterior visual pathways include the more commonly encountered benign tumors of children and the rare and highly aggressive malignant tumors of adults. Diagnostic biopsy is not required in most cases of childhood gliomas, especially those unassociated with visual loss or other neurologic symptoms, because the clinical and neuroimaging features are often sufficiently characteristic. Because of the infiltrative nature of these tumors, the neurosurgeon has little to offer symptomatic patients beyond debulking large exophytic masses and shunting if hydrocephalus is present.

Serum vitamin A concentration is elevated in idiopathic intracranial hypertension.

OBJECTIVE: The primary purpose was to investigate whether serum vitamin A concentration is associated with idiopathic intracranial hypertension (IIH). The secondary aim was to obtain pilot data regarding the amount of vitamin A ingested by patients and controls. BACKGROUND: Vitamin A is an attractive candidate mediator of IIH as many of the symptoms and signs of hypervitaminosis A mimic those of IIH. METHODS: We prospectively determined serum retinol and retinyl ester concentration in 16 women with IIH and 70 healthy young women. Using a survey instrument, we also determined the average daily vitamin A ingestion in a convenience sample of patients and controls. RESULTS: Serum retinol concentration was significantly higher in the patient group (median 752 ug/L) compared with the control group (median 530 ug/L), even after adjusting for age and body mass index (p < 0.001). Retinyl ester concentration, however, was similar in the patient (median 48 ug/L) and control (median 41 ug/L) groups (p = 0.32). There was no significant correlation between serum retinol concentration and body mass index in the patients (r = 0.16) or controls (r = -0.02). Finally, there was no significant difference in the amounts of vitamin A ingested by the patients or controls, although the small number of subjects in both groups reduced the power of this conclusion. CONCLUSIONS: Elevated serum retinol concentration is associated with IIH. Obesity, by itself, does not explain these higher levels. Patients may ingest an abnormally large amount of vitamin A, metabolize it abnormally, or be unusually sensitive to its effects. Alternatively, elevated level of serum retinol may reflect an epiphenomenon of another variable we did not measure or a nonspecific effect of elevated retinol binding capacity.

The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy.

PURPOSE: To discuss the sensitivity of three-dimensional time-of-flight (3D TOF) magnetic resonance angiography (MRA) for detecting aneurysms causing third cranial nerve palsy and to propose guidelines for the use of MRA in the evaluation of patients with different clinical presentations of oculomotor nerve palsy. METHODS: From a review of the scientific literature, we determined the proportion of aneurysms of various size that cause third nerve palsy, the sensitivity of MRA in detecting aneurysms of these size classes, and the relationship of aneurysmal size to rupture. RESULTS: The data disclose that properly performed and interpreted 3D TOF MRA will overlook only 1.5% of aneurysms producing third cranial nerve palsy that will, if untreated, rupture during the subsequent 8 years. CONCLUSIONS: Magnetic resonance angiography plays an important diagnostic role in the evaluation of patients with isolated third cranial nerve palsy. However, because of the potentially drastic consequences of overlooking an aneurysm, MRA should be the definitive screening test only among patients with a relatively low likelihood of harboring an aneurysm or a relatively high likelihood of suffering a complication from catheter angiography.

Isolated trochlear nerve palsy in patients with multiple sclerosis.

The authors describe five patients with trochlear nerve palsy and MS to characterize this rare association. In two patients, trochlear nerve palsy was the initial clinical manifestation of MS. In the other three patients, this sign occurred after previous neurologic events. MRI did not identify a lesion of the fourth nerve nucleus or fascicle. Ophthalmoplegia resolved within 2 months in four of the five patients. A reason this association is rare is that the fascicular course of the trochlear nerve is exposed to little myelin.

Compression of the prechiasmatic optic nerve produces a junctional scotoma.

PURPOSE: To demonstrate the clinical-radiologic correlation between a junctional scotoma and a focal lesion compressing the prechiasmatic segment of the distal optic nerve. METHODS: Case report involving a man with a pituitary adenoma. Clinical correlation was determined by reviewing visual field evaluations and magnetic resonance images. RESULTS: The tumor compressed the prechiasmatic segment of the distal optic nerve but not the optic chiasm, producing a junctional scotoma documented by Goldmann and automated perimetry. The visual field defect resolved after neurosurgical decompression of the anterior visual pathway. CONCLUSIONS: A junctional scotoma can be caused by focal as well as large and diffuse lesions injuring the anterior visual pathway, specifically at the junction of the optic nerve and chiasm. This finding supports the existence of Wilbrand fibers.

Proptosis with acute oculomotor and abducens nerve palsies.

OBJECTIVE: To determine whether orbital axial proptosis occurs in the affected eye of patients with acute oculomotor or abducens nerve palsy. MATERIALS AND METHODS: In this prospective, cross-sectional survey, the Hertel instrument was used to measure the amount of axial protrusion in 26 consecutive patients with complete or severe acute oculomotor nerve palsy and 27 consecutive patients with complete or severe acute abducens nerve palsy. The Mann-Whitney test was used to compare the amount of relative proptosis of the affected eye in the patient groups with that of 40 control subjects. The absolute amount of the interocular difference in axial protrusion of the normal eyes was used to determine control values. The proportion of patients and control subjects with relative proptosis greater than 1 mm was compared using Fisher's exact test. RESULTS: There was no significant difference in the degree of relative proptosis of the affected eye of patients with oculomotor nerve palsy or abducens nerve palsy as compared with the control eyes. Likewise, there was no significant difference in the proportion of patients with relative proptosis greater than 1 mm in either the oculomotor nerve palsy group or the abducens nerve palsy group as compared with the control group. CONCLUSIONS: Acute oculomotor or abducens nerve palsy does not produce any significant amount of orbital axial proptosis in the affected eye, at least as measured clinically using the Hertel instrument. Acute neurogenic ophthalmoplegia rarely causes relative proptosis greater than 1 mm.