Randomized double-blind crossover study of the efficacy of a tart cherry juice blend in treatment of osteoarthritis (OA) of the knee.

OBJECTIVE: To assess the efficacy of tart cherry juice in treating pain and other features of knee osteoarthritis (OA). METHODS: 58 non-diabetic patients with Kellgren grade 2-3 OA were randomized to begin treatment with cherry juice or placebo. Two 8 oz bottles of tart cherry juice or placebo were consumed daily for 6 weeks with a 1 week washout period before switching treatments (crossover design). Western Ontario McMaster Osteoarthritis Index (WOMAC) scores and walking times were recorded prior to and after each treatment period. Additionally, plasma urate, creatinine and high sensitivity C-reactive protein (hsCRP) were recorded at baseline, after the first treatment period and after the second treatment period. Acetaminophen was allowed as a rescue drug and self reported after each treatment period. Treatment effect was examined with repeated measures analysis of variance (ANOVA) using an intention-to-treat (ITT) analysis. RESULTS: There were five withdrawals during the cherry juice treatment (four adverse events (AEs)) and seven withdrawals during the placebo treatment (three AEs). WOMAC scores decreased significantly (P < 0.01) after the cherry juice treatment but not after the placebo treatment (P = 0.46); differences between treatments were not significant (P = 0.16). hsCRP declined during the cherry juice treatment vs placebo (P < 0.01). The decline in hsCRP was associated with WOMAC improvement (P < 0.01). Walking time, acetaminophen use, plasma urate and creatinine were unaffected by treatments. CONCLUSIONS: Tart cherry juice provided symptom relief for patients with mild to moderate knee OA, but this effect was not significantly greater than placebo. Tart cherry juice lowered hsCRP levels and this effect was associated with improved WOMAC scores.

Adalimumab for moderate to severe chronic plaque psoriasis: efficacy and safety of retreatment and disease recurrence following withdrawal from therapy.

BACKGROUND: Adalimumab is effective for moderate to severe chronic plaque psoriasis; however, data regarding retreatment following withdrawal and subsequent relapse are limited. OBJECTIVES: To evaluate the efficacy and safety of adalimumab if interrupted and then resumed in patients with moderate to severe psoriasis. METHODS: Patients in a long-term adalimumab open-label extension study (NCT00195676) who achieved a Physician's Global Assessment (PGA) score of 'Mild' (2), 'Minimal' (1) or 'Clear' (0) were withdrawn from adalimumab and monitored for relapse to PGA of 'Moderate' (3) or worse. The subgroup of interest had stable psoriasis control, defined as PGA of 0/1 for ≥12 weeks on every other week (eow) dosing before withdrawal. Relapsing patients were retreated with adalimumab (80 mg at week 0 and 40 mg eow starting at week 1). PGA, Psoriasis Area and Severity Index responses, fatigue, pharmacokinetics and immunogenicity were assessed. RESULTS: In total, 525 patients were withdrawn from adalimumab; the subgroup with stable psoriasis control comprised 285 patients. Of these, 178 relapsed (median=141 days) before treatment reinitiation and 107 did not relapse. Patients without relapse by 40 weeks off therapy reinitiated adalimumab. Rates of PGA 0/1 after 16 weeks of adalimumab retreatment were 89% for patients without relapse and 69% for patients who relapsed. Relapsers experienced significantly less fatigue after retreatment. Nine patients (3%) had serious adverse events (two were infections). No rebound or allergic reactions occurred. CONCLUSIONS: Adalimumab-treated patients who discontinued therapy and subsequently relapsed had a good likelihood of regaining clinical efficacy following adalimumab reinitiation.

Economic burden of comorbidities in patients with psoriasis is substantial.

BACKGROUND: Psoriasis is frequently associated with comorbidities. OBJECTIVE: To estimate the incremental economic burden associated with comorbidities in patients with psoriasis, accounting for psoriasis severity. METHODS: Patients continuously enrolled ≥6 months after a randomly selected psoriasis diagnosis date were selected from the Ingenix Impact National Managed Care Database (1999-2004). Comorbidities identified during the 6-month study included: psoriatic arthritis, cardiovascular disease, depression, diabetes, hyperlipidemia, hypertension, obesity, cerebrovascular diseases and peripheral vascular disease. Resource utilization and costs during the 6-month follow-up period were compared for patients with ≥1 comorbidity vs. those without and for patients with a specific comorbidity vs. those without. Adjusted incidence rate ratios (IRRs) and odds ratios (ORs) were estimated for resource utilization using negative binomial and logistic regression models, respectively. Adjusted incremental costs associated with comorbidities were reported using general linear models with log-link and gamma distributions or two-part models. Models controlled for age, sex and psoriasis severity. RESULTS: A total of 114,512 patients were included; 51% had ≥1 comorbidity. Hyperlipidemia (27%) and hypertension (25%) were most prevalent. Patients with comorbidities were more likely to experience urgent care [OR (95% confidence interval (CI))=1.58 (1.51-1.65)] than patients without comorbidities. They also had significantly greater hospitalization rates [IRR (95% CI)=2.27 (2.13-2.42)] and outpatient visits [IRR (95% CI)=1.53 (1.52-1.55)]. Compared with patients who did not have comorbidities, patients with comorbidities incurred $2184 (P<0.001) greater total costs. CONCLUSION: Comorbidities present a significant economic burden in patients with psoriasis.

Phenotypic variability and therapeutic implications of Candida species in patients with oral lichen planus.

We investigated the prevalence and phenotypic variation of Candida species in oral lichen planus (OLP) and the therapeutic implications of our findings. Eighty patients with clinically and histopathologically confirmed cases of OLP (64 non-erosive, 16 erosive) and a control group of 80 healthy individuals with no predisposing factors for oral candidiasis were examined for evidence of Candida infection. Oral swabs and smears were obtained for cytology and culture. Identification, speciation and antifungal susceptibility tests of Candida isolates were performed using an automated microbial identification system. Fifty percent of erosive OLP cases, 28% of non-erosive cases and none of the controls showed evidence of Candida. Candida albicans was found predominantly in non-erosive OLP, while other Candida species were predominate in erosive OLP. Non-Candida albicans isolates (C. glabrata, C. krusei) were resistant to the commonly used antifungals, clotrimazole and fluconazole. Candida infection is common in cases of OLP. We recommend antifungal sensitivity testing prior to antifungal therapy for the erosive form of OLP.

Dexamethasone implant in diabetic macular edema in real-life situations.

PURPOSE: To report outcome of eyes with recalcitrant and naive eyes with diabetic macular edema (DME) treated with intravitreal dexamethasone implants (Ozurdex) injection. METHODS: Retrospective multicenter data analysis of eyes with DME treated with Ozurdex implant and with minimum follow-up of at least one year after the first implant. Data collected included demographic details, history of presenting illness, past treatment history, clinical examination details including visual acuity at presentation, and follow-up with imaging and treatment details. Paired sample t-test was used to measure mean differences between pre- and post-implant values obtained at baseline and last follow-up. RESULTS: A total of 79 eyes (62 subjects) were included. Sixty-four eyes had been previously treated; 15 eyes were naive. Among the previously treated eyes, mean interval between first Ozurdex injection and any previous treatment was 7.69±8.2 months. In naive eyes, the visual acuity improved from baseline 0.58±0.25 to 0.44±0.33 logMAR at last follow-up (P=0.05). In eyes that had been previously treated, the improvement was from 0.65±0.34 at baseline to 0.48±0.35 logMAR (P=0.01). Mean treatment-free interval was 6.5±4.5 months. Nine eyes were steroid responder with controlled intraocular pressure (IOP), none showed any spike in IOP during the follow-up period. CONCLUSIONS: Ozurdex implant could be a good alternative for recalcitrant as well as naive eyes with DME. The visual gain after initial implant injection was fairly maintained, with additional treatment usually after 6 months in naive eyes. Ozurdex appeared safe even in steroid responders with good control of IOP with antiglaucoma medications.

Periventricular white matter changes and dementia. Clinical, neuropsychological, radiological, and pathological correlation.

Forty-three patients with computed tomographic scan findings of decreased attenuation in the periventricular white matter (PVWM) region were studied. Clinical evaluation revealed presence of hypertension in 36 patients (84%) and cerebrovascular risk factors in 41 patients (95%). Unilateral or bilateral neurological deficits were present in 40 patients (93%). Neuropsychological evaluation in 27 of them revealed features of subcortical dementia. Magnetic resonance imaging in seven cases demonstrated high-intensity areas in the deep white matter region on T2-weighted imaging. Pathological evaluation in four patients revealed demyelination without inflammatory cells and infarctions in the PVWM region, lacunar infarctions in the basal ganglia and brain stem, and marked arteriosclerosis. The study indicated that most (95% in this series) of the patients with computed tomographic scan findings of decreased attenuation in the PVWM region had cerebrovascular risk factors and various neurological and neuropsychological features of subcortical dementia. Pathologically, these lesions represented areas of infarction and demyelination, along with diffuse arteriosclerosis.

Cranial neuropathy in systemic malignancy in a VA population.

We studied 30 men with cranial neuropathy (CN) and systemic malignancy to determine the etiology and prognosis of CN. The most common malignancy was prostate (33%), followed by lung (27%). The etiology of CN was metastatic in 25 (83%) and nonmetastatic in 5 (17%). Only 6 patients improved: 3 metastatic and 3 nonmetastatic. Although prognosis for recovery was better in the nonmetastatic group, there was no significant difference in survival between the metastatic and the nonmetastatic groups.

Bromocriptine treatment of nonfluent aphasia.

Using a double-blind, placebo-controlled, crossover design, we studied the effect of bromocriptine (15 mg daily) in 20 men with chronic nonfluent aphasia. The study was conducted over a 28-week period in two phases. In phase I, the patients received either bromocriptine or placebo; in phase II the treatments were crossed over. We evaluated each patient's language and nonverbal cognitive skills at the beginning and end of each phase and 6 weeks after completion of phase II. When compared with placebo treatment, bromocriptine did not significantly improve the patient's speech fluency, language content, overall degree of aphasia severity, or nonverbal cognitive abilities. Based on these results, bromocriptine is not recommended as monotherapy for the treatment of chronic nonfluent aphasia.

Higher prevalence of abdominal aortic aneurysms in patients with carotid stenosis but without diabetes.

BACKGROUND: We compared abdominal aortic aneurysm (AAA) prevalence in 3 groups of patients at the Hines Veterans Affairs Medical Center: (1) patients with 50% or more carotid stenosis, (2) patients with less than 50% stenosis, and (3) patients screened for the Aneurysm Detection and Management (ADAM) study. METHODS: Of all the patients referred to the vascular laboratory for carotid duplex examination during a 12-month period, patients with 50% or more carotid stenosis underwent ultrasonography of the abdominal aorta unless they had a previous scan or previous aortic surgery (group 1, n = 374). Patients with less than 50% carotid stenosis who had been screened for ADAM comprised group 2 (n = 139). They were compared with all patients screened for ADAM at our center during the same time period (group 3, n = 2477). RESULTS: AAA of 3.0 cm or more were present in 18.2%, 12.2%, and 7.2% of groups 1, 2, and 3, respectively; AAA of 4.0 cm or more were present in 8.3%, 5.8%, and 2.1% of groups 1, 2, and 3, respectively. Among patients with carotid stenosis, those patients without diabetes accounted for the observed increase in prevalence (21.9 % > or = 3.0 cm and 10.2% > or = 4.0 cm vs 9.2% and 2.8% in patients with diabetes). CONCLUSIONS: The relative risk of AAA is 2 to 3 times greater in patients with carotid stenosis compared with patients undergoing routine screening. However, only patients without diabetes account for the increased prevalence. Selective AAA screening of patients who are not diabetic with carotid stenosis is recommended.

Genetic heterogeneity in familial exudative vitreoretinopathy; exclusion of the EVR1 locus on chromosome 11q in a large autosomal dominant pedigree.

BACKGROUND/AIMS: Familial exudative vitreoretinopathy (FEVR) is associated with mutations in the Norrie disease gene in X linked pedigrees and with linkage to the EVR1 locus at 11q13 in autosomal dominant cases. A large autosomal dominant FEVR family was studied, both clinically and by linkage analysis, to determine whether it differed from the known forms of FEVR. METHODS: Affected members and obligate gene carriers from this family were examined by slit lamp biomicroscopy, indirect ophthalmoscopy, and in some cases fluorescein angiography. Patient DNAs were genotyped for markers at the EVR1 locus on chromosome 11q13. RESULTS: The clinical evaluation in this family is consistent with previous descriptions of FEVR pedigrees, but linkage analysis proves that it has a form of FEVR genetically distinct from the EVR1 locus on 11q. CONCLUSION: This proves that there are at least three different loci associated with comparable FEVR phenotypes, a situation similar to that existing for many forms of retinal degeneration.

Primary intraventricular hemorrhage in adults: clinical features, risk factors, and outcome.

BACKGROUND AND PURPOSE: Nontraumatic primary intraventricular hemorrhage in adults is uncommon. The purpose of this study was to identify clinical features, risk factors, and outcome of primary intraventricular hemorrhage in adults. METHODS: We identified computed tomography scans for nontraumatic primary intraventricular hemorrhage performed between 1982 and 1993 at our institutions and reviewed medical records to determine clinical features, risk factors, and outcomes of these patients. RESULTS: Of 14 cases studied, the onset of symptoms was acute in all and the most common symptom was headache (78%), followed by nausea/vomiting (71%), and mental status change (71%). Seizures as well as focal neurologic deficits were uncommon. The associated risk factors were hypertension in 7 cases, aneurysm or arteriovenous malformation in 5, coagulopathy in 1, and fibromuscular dysplasia in 1 case. Five patients died acutely, and all of the survivors returned to functional independence. The patients with lethargy, pupillary and extraocular movement abnormalities, quadriparesis, hydrocephalus, and aneurysmal intraventricular hemorrhage had worse outcomes. CONCLUSION: Patients with nontraumatic primary intraventricular hemorrhage present with sudden onset of diffuse neurologic symptoms. The mortality in early phase is high (36%) and the prognosis for survivors is good. Factors correlating with the outcome are discussed.

Foster-Kennedy syndrome due to optochiasmatic arachnoiditis.

A case of optochiasmatic arachnoiditis mimicking Foster-Kennedy syndrome is reported. The difficulties in establishing diagnosis are considered, and the literature of optochiasmatic arachnoiditis presenting in this unusual manner is reviewed.

Outcome of asymptomatic cervical bruits in a veteran population.

The potential risk of stroke in patients with a localized asymptomatic cervical bruit continues to be a source of debate. We identified 273 patients with 374 asymptomatic mid-cervical bruits. Using Doppler with spectral analysis, the internal carotid artery (ICA) was stratified into one of three groups; greater than or less than 75% cross section area stenosis, or occlusion. Each carotid artery was evaluated for progression of stenosis and occurrence of neurologic events (TIA's and strokes). During an average follow-up of 29.6 months, 26 neurologic events (10 strokes, 16 TIA's) occurred ipsilateral to the carotid bruits. Most asymptomatic bruits (308/374; 82%) were associated with carotid arteries having less than 75% stenosis and the risk of stroke from those arteries remaining at less than 75% stenosis (254/308) was 1.5%. However, progression to greater than 75% stenosis or occlusion as determined at the most recent noninvasive examination (54/308) was associated with a significant risk for stroke (7.4%; p less than 0.001). Progression to occlusion in the total population was highly significant for the risk of developing stroke (4 out of 19; p less than 0.001).

Modified instruments for wrist fusion.

A technique and new instruments for intramedullary fixation of the wrist arthrodesis is described, based on the technique of Clayton, popularized by Nalebuff and Millender. This allows early mobilisation, secure fixation and simplicity of the technique. It also allows other surgical procedures to be performed under the same anaesthetic and tourniquet due to the reduction in operative time.

Subaortic stenosis associated with anomalous right ventricular muscle bundle and ventricular septal defect.

A rare case of biventricular outflow tract obstruction in the form of discrete subaortic membrane and hypertrophic anomalous right ventricular muscle bundle associated with ventricular septal defect is presented.

Correlation of 12 lead ECG QRS score with severity of aortic stenosis.

The hemodynamic data and electrocardiograms of thirty-three patients of moderate to severe aortic stenosis were analysed retrospectively to find out if there was any correlation between 12 lead ECG-QRS score and left ventricular peak systolic pressure (LVPSP) and/or peak systolic gradient (PSG) across the aortic valve. The mean age of the study population was 33.33 (+/- 15.02SD) years, with the male to female ratio being 9:2. The mean 12 lead ECG-QRS score in these 33 patients was 281 mm (+/- 46.02SD), the mean LVPSP 203.52 mmHg (+/- 46.62SD) and the mean PSG across the aortic valve was 81.0 mmHg (+/- 41.62SD). There was good correlation of 12 lead ECG-QRS score with LVPSP (r = 0.47, P less than 0.001) and with PSG across the aortic valve (r = 0.58, P less than 0.001), latter being more significant. The best correlation was however found between 12 lead ECG-QRS score and PSG across the aortic valve in patients over 35 years of age (r = 0.88). In conclusion there is a direct relationship between 12 lead ECG-QRS score and peak systolic gradient across the aortic valve and the latter can be approximately calculated non-invasively with the help of regression equation- Peak systolic gradient (in mmHg) = 12 lead ECG-QRS score/3 - 10.6

Abnormal facial movements. Guide to differential diagnosis.

Spontaneous facial movements are disturbing to those who have them, yet some such movements are benign and cause no more than cosmetic embarrassment. Other abnormal facial movements, however, are more serious and can be associated with neurologic disorders such as multiple sclerosis, brainstem tumor, peripheral neuropathy, and Guillain-Barré syndrome. Occasionally, an abnormal movement of the face is the first sign of such an underlying disorder. Accurate differential diagnosis of these perplexing movement disorders is imperative in determining prognosis.

Prognosis in non-traumatic coma.

We conducted serial neurological examinations on 50 patients of non-traumatic coma to identify factors predicting recovery. During the course of the study 40 (80 percent) patients died, 1 (2 percent ) survived with sever disability, 3 (6 percent) survived with moderate disability and 6 (12 percent) made good recovery. Status of pupillary and oculocephalic reflex was found to be statistically significant to judge the prognosis. No patient made good recovery when any two brain stem reflexes were absent.

The human vas-its lumen in relation with age and neuromuscular transmitters.

Specimens of human was deferens were obtained during elective surgery under local analsthesia. The internal diameter of the vas lumen was measured by means of set of rods of 0.10 mm diameter increments. These measurements were made within 5 minutes of the removal of vas and noted as control values. The effect of its immersion in epinephrine 1/1000, nor-epinephrine 1/1000 and acetylcholine 1/1000 on diameter of lumen was determined. The mean diameter of vas lumen in saline was 0.83 +/- .09 mm in subjects of 29 to 32 years age and 0.89 +/- .009 mm in subject of 33 to 48 years. This value was significantly lower in subjects of 49 to 52 years (0.69 +/- .06 mm). The lumen diameter decreased significantly in response to epinephrine and nor epinephrine and increased when the vas was immersed in acetylcholine. The response of vasal smooth muscle as indicated by alteration of lumen size was significantly lower in subjects of 49 to 52 years of age to epinephrine and acetylcholine. It has been proposed that diameter of the vas at different age groups and its responsiveness to neuromuscular transmitters may be taken into consideration when designing vas occlusive devices.

Successful therapeutic management of concurrent subclinical Eimeria leukarti and Babesia (Theileria) equi infection in a mare.

The occurrence of Eimeria leukarti infection in equine is being sporadically documented despite its cosmopolitan prevalence. A Marwari mare, aged 3 years and 6 months and owned by a socio-economically weaker class of labourer of royal families, was suffering from non specific enteric disorders. Detailed systemic clinical examination of mare confirmed subclinical enteric infection with E. leukarti and piroplasms of Babesia (Theileria) equi in the circulating erythrocytes. She was therapeutically managed with synchronous administration of specific and supportive therapy with success. Non specific clinical manifestations of the disease in equines, its debatable pathogenic significance, predisposing immunosuppressive impact of concurrent B. (T.) equi in circulating erythrocytes and probable reasons for under reporting of the disease in equines, etc. have been discussed.