Healthcare attendance styles among long-term unemployed people with substance-related and mood disorders.

BACKGROUND: Both increased and decreased health service usage and unmet care needs are more prevalent among unemployed people than in the general population. STUDY DESIGN: This study investigates the associations of substance-related and mood disorders among long-term unemployed people with styles of healthcare attendance in Finland. METHODS: The study material consisted of the health register information on 498 long-term unemployed people in a project screening for work disabilities. The data were analysed by mixed methods: qualitative typological analysis was applied to identify differential healthcare attendance styles, and the associations of the obtained styles with mental health disorders were analysed quantitatively by multinomial logistic regression. RESULTS: Three styles, characterized as smooth, faltering and marginalized, were identified. Compared with participants with the smooth attendance style without mental disorders, those with the faltering style had tenfold relative risk for substance-related disorder and fourfold relative risk for mood disorder. Those with the marginalized style had fivefold relative risk for substance-related disorder and twofold relative risk for mood disorder. Adjusting for background characteristics did not alter the statistical significance of substance-related disorder. In the case of mood disorders, the statistical significance persisted throughout the adjustments in the faltering style. CONCLUSION: Dysfunctional use of health services is more common among people with substance-related or mood disorders, who are at risk of drifting towards long-term unemployment and work disabilities. The early detection of those with faltering or marginalized healthcare attendance style may prevent prolonged unemployment, enable rehabilitation measures and reduce the risk of disability pensions.

Clinical correlates of cerebral diffusion tensor imaging findings in chronic traumatic spinal cord injury.

STUDY DESIGN: Prospective clinical case-control study. OBJECTIVES: The aim of this study was to use diffusion tensor imaging (DTI) to assess the state of cerebral white matter tracts after spinal cord injury (SCI). The DTI metrics were evaluated in relation to neurological deficits and to the size and level of the spinal cord lesions. SETTING: Tampere University Hospital, Tampere, Finland. METHODS: Thirty-four patients (n=34) with clinically complete and incomplete SCI were evaluated using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). DTI metrics (fractional anisotropy (FA) and apparent diffusion coefficient (ADC)) were calculated for multiple levels along the course of the corticospinal tract. The state of the spinal cord after injury was assessed using conventional magnetic resonance imaging (MRI). DTI parameters were compared with 40 orthopedically injured control subjects. RESULTS: Statistically significant differences in the DTI values between patients and controls were detected in the posterior area of the centrum semiovale. In this area, the FA values were lower in the patients compared with controls (P=0.008). For patients with clinically complete injury, the difference was even more significant (P=0.0005). Motor and sensory scores of the ISNCSCI correlated positively with FA and negatively with ADC values of the centrum semiovale. A moderate association was observed between the macroscopic changes in the spinal cord and the DTI abnormalities in the centrum semiovale. CONCLUSION: In patients with chronic SCI, DTI changes can be observed in the cerebral white matter. These alterations are associated with the clinical state of the patients.

Fluidized-bed denitrification for mine waters. Part II: effects of Ni and Co.

The dispersion of nitrogenous compounds and heavy metals into the environment is frequent during mining activities. The effects of nickel (Ni) and cobalt (Co) on denitrification of simulated mine waters were investigated in batch bioassays and fluidized-bed reactors (FBRs). At pH 7, batch tests revealed that Co did not exhibit inhibition on denitrification even at 86.6 mg/L. Ni showed to be inhibitory at 50 and 100 mg/L by decreasing nitrate removal efficiencies of 18 and 65 %, respectively. In two FBRs, operated at 7-8 and 22 °C, 5.5 mg/L Ni did not affect nitrate and nitrite removals because of FBR potential of diluting soluble Ni feed concentration. On the contrary, the effluent pH clearly decreased in both FBR1 and FBR2 because of nickel sulfide precipitation and Ni inhibition of the last two steps of denitrification. When Ni injection was stopped, the process recovered more slowly at 22 than 7-8 °C. This is the first study reporting the effect of Ni on denitrification in biological FBRs.

Fluidized-bed denitrification for mine waters. Part I: low pH and temperature operation.

Mining often leads to nitrate and metal contamination of groundwater and water bodies. Denitrification of acidic water was investigated in two up-flow fluidized-bed reactors (FBR) and using batch assays. Bacterial communities were enriched on ethanol plus nitrate in the FBRs. Initially, the effects of temperature, low-pH and ethanol/nitrate on denitrification were revealed. Batch assays showed that pH 4.8 was inhibitory to denitrification, whereas FBR characteristics permitted denitrification even at feed pH of 2.5 and at 7-8 °C. Nitrate and ethanol were removed and the feed pH was neutralized, provided that ethanol was supplied in excess to nitrate. Subsequently, Fe(II) and Cu impact on denitrification was investigated within batch tests at pH 7. Iron supplementation up to 100 mg/L resulted in iron oxidation and soluble concentrations ranging from 0.4 to 1.6 mg/L that stimulated denitrification. On the contrary, 0.7 mg/L of soluble Cu significantly slowed denitrification down resulting in about 45 % of inhibition in the first 8 h. Polymerase chain reaction-denaturant gradient gel electrophoresis demonstrated the co-existence of different denitrifying microbial consortia in FBRs. Dechloromonas denitrificans and Hydrogenophaga caeni were present in both FBRs and mainly responsible for nitrate reduction.

Dysphagia and dysphonia among persons with post-polio syndrome - a challenge in neurorehabilitation.

OBJECTIVE: To study the occurrence of dysphagia and dysphonia in persons with post-polio syndrome admitted into the centre for neurological rehabilitation in Finland. MATERIALS AND METHODS: Fifty-one persons with post-polio syndrome who were rehabilitated at Käpylä Rehabilitation Centre, Helsinki, Finland, in 2003-2004 were interviewed on problems with swallowing and voice production. Pulmonary function testing and grip strength measurement were performed. A clinical assessment of oral motor and laryngeal functions was carried out for those who reported daily problems with voice production or swallowing. RESULTS: Fifteen persons (29.4%) reported daily problems with swallowing or voice production. In the clinical assessment, the most commonly observed deficits in swallowing included decreased pharyngeal transit (n = 13) and the food catching in the throat (n = 4). The disturbance of co-ordination of breathing and voice production was seen in 12 persons. There were no significant differences in any of the potential predictors between the groups. CONCLUSIONS: Professionals need to be aware of the routine evaluation of dysphagia and dysphonia in patients with post-polio syndrome.

Inhibitory CA1-CA3-hilar region feedback in the hippocampus.

The organization of the hippocampus is generally thought of as a series of cell groups that form a unidirectionally excited chain, regulated by localized inhibitory circuits. With the use of in vivo intracellular labeling, histochemical, and extracellular tracing methods, a longitudinally widespread, inhibitory feedback in rat brain from the CA1 area to the CA3 and hilar regions was observed. This long-range, cross-regional inhibition may allow precise synchronization of population activity by timing the occurrence of action potentials in the principal cells and may contribute to the coordinated induction of synaptic plasticity in distributed networks.

The benefit of active drug trials is dependent on aetiology in refractory focal epilepsy.

BACKGROUND: Earlier studies have shown that aetiology makes a difference in the outcome of epilepsy, but there is a paucity of follow-up studies to evaluate the possibilities of achieving seizure freedom in initially refractory epilepsy. METHODS: We evaluated the cause of epilepsy based on high-resolution brain MRI and patient history in 119 consecutive thoroughly examined adult patients with refractory focal epilepsy followed up in our centre. We also evaluated the influence of aetiology and duration of epilepsy in this patient cohort on the chances of achieving 12-month remission in a 2-year follow-up. RESULTS: The major finding was that a substantial group of patients achieved remission; 30 (25%) initially refractory patients achieved at least 12 months remission during follow-up. A total of 40.0% of the patients with cryptogenic aetiology had achieved 12-month remission compared with the 16.2% patients with symptomatic aetiologies (age-adjusted OR 3.74, 95% CI 1.54 to 9.07, p = 0.004). Aetiologies often considered for surgical treatment (hippocampal sclerosis, cortical dysplasia, vascular malformation, tumour and dual pathology) carried an almost six-fold risk of persistent seizures compared with cryptogenic epilepsy (age-adjusted OR 5.85, 95% CI 2.00 to 17.11, p = 0.001). CONCLUSIONS: Patients with vascular malformation and dual pathology as aetiology were most refractory, none being in remission for 12 months. There were also patients achieving 12-month remission after a long period of active epilepsy. These results encourage physicians to continue with new drug trials, especially on patients with no possibilities of epilepsy surgery, as well as on those still having seizures after epilepsy surgery.

Long-term efficacy and cognitive effects of vigabatrin.

Vigabatrin is effective as add-on therapy in about 50% of patients with partial epilepsy refractory to drugs. Furthermore, at least half of the original responders maintain the response over several years. As monotherapy, both vigabatrin and carbamazepine seem to be successful in a similar proportion of newly diagnosed patients with epilepsy, but carbamazepine monotherapy fails more often due to side-effects and vigabatrin more often due to lack of efficacy. However, vigabatrin monotherapy seems to be extremely well tolerated, particularly in relation to cognitive function.

The hippocampal CA3 network: an in vivo intracellular labeling study.

The intrahippocampal distribution of axon collaterals of individual CA3 pyramidal cells was investigated in the rat. Pyramidal cells in the CA3 region of the hippocampus were physiologically characterized and filled with biocytin in anesthetized animals. Their axonal trees were reconstructed with the aid of a drawing tube. Single CA3 pyramidal cells arborized most extensively in the CA1 region, covering approximately two-thirds of the longitudinal axis of the hippocampus. The total length of axon collaterals in the CA3 region was less than in CA1 and the axon branches tended to cluster in narrow bands (200-800 microns), usually several hundred microns anterior or posterior to the cell body. The majority of the recurrent collaterals of a given neuron remained in the same subfield (CA3a, b, or c) as the parent cell. CA3a neurons innervated predominantly the basal dendrites, whereas neurons located proximal to the hilus (CA3c) terminated predominantly on the apical dendrites of both CA1 and CA3 cells. Two cells, with horizontal dendrites and numerous thorny excrescences at the CA3c-hilus transitional zone, were also labeled and projected to both CA3 and CA1 regions. All CA3 neurons projected some collaterals to the hilar region. Proximal (CA3c) neurons had numerous collaterals in the hilus proper. One CA3c pyramidal cell in the dorsal hippocampus sent an axon collaterals to the inner third of the molecular layer. CA3c pyramidal cells in the ventral hippocampus had extensive projections to the inner third of the dentate molecular layer, as well as numerous collaterals in the hilus, CA3, and CA1 areas, and several axon collaterals penetrated the subiculum. The total projected axon length of a single neuron ranged from 150 to 300 mm. On the basis of the projected axon length and bouton density (mean interbouton distance: 4.7 microns), we estimate that a single CA3 pyramidal cell can make synapses with 30,000-60,000 neurons in the ipsilateral hippocampus. The concentrated distribution of the axon collaterals ("patches") indicates that subpopulations of neurons may receive disproportionately denser innervation, whereas innervation in the rest of the target zones is rather sparse. These observations offer new insights into the physiological organization of the CA3 pyramidal cell network.

Morphometric and electrical properties of reconstructed hippocampal CA3 neurons recorded in vivo.

CA3 pyramidal neurons were stained with biocytin during intracellular recording in rat hippocampus in vivo and reconstructed using a computer-based system. The in vivo CA3 neurons were characterized primarily according to their proximity to the hilus and secondarily with respect to the septotemporal location. Neurons measured in CA3a (n = 4), in CA3b (n = 4), and in posterior/ventral locations (n = 3) had the greatest dendritic lengths (19.8, 19.1, and 26.8 mm on average, respectively). Cells closer to the hilus showed much shorter dendritic lengths, averaging 10.4 mm for CA3c neurons (n = 4) and 11.6 mm for zone 3 neurons (n = 2). Half of the cells showed more than one major apical dendrite, and dendritic trees were highly variable even within CA3 subregions. The mean electronic length for these cell groups averaged between 0.30 lambda (CA3c) and 0.45 lambda (posterior/ventral), assuming a constant specific-membrane resistivity of 60 K omega-cm2. These CA3 neurons form a database of reconstructed neurons for further morphometric and electrical modelling studies. The large degree of variability between individual CA3 neurons indicates that both dendritic and electrical properties should be specifically calculated for each cell rather than assuming a "typical" morphology.

Long-term study with gabapentin in patients with drug-resistant epileptic seizures.

OBJECTIVE: To study the efficacy and safety of gabapentin in long-term treatment. DESIGN: A 4-year follow-up study of 25 patients with visits at 3-month intervals. SETTING: The patients were followed up in the outpatient unit of the University Hospital of Kuopio (Finland). PATIENTS: We treated 25 patients with drug-resistant complex partial seizures and secondarily generalized seizures in an open-label long-term study, using gabapentin as an additional means of therapy after a 3-month double-blind, placebo-controlled phase. Thirteen patients showed no benefit from gabapentin; the study medication was discontinued after 4 to 6 months of treatment. Of the 12 patients who responded enough to continue treatment, five were withdrawn due to different reasons, one because of loss of response. MAIN OUTCOME MEASURES: The number of patients receiving the study drug in the follow-up and reduction of seizure frequency from baseline level as analyzed by the Wilcoxon test. RESULTS: Seven patients received gabapentin therapy for more than 4 years. The median follow-up time was 54 months. There was a significant reduction in seizure frequency throughout the follow-up period. Five of seven patients had a greater than 50% seizure frequency reduction at 4 years, representing 20% of the 25 patients who entered the study. CONCLUSIONS: Gabapentin possesses good efficacy in long-term treatment of patients with partial and secondarily generalized epileptic seizures. It is safe to use, and it is fairly well tolerated even in long-term treatment.

The importance of the electrocardiogram in ambulatory electroencephalographic recordings.

The role of an ambulatory electroencephalogram performed simultaneously with an electrocardiogram was studied in 861 neurologic inpatients. In total, 123 patients (14%) had interictal cardiac rhythm abnormalities, and 31 (4%) had neurologic symptoms considered to be of cardiac origin. The occurrence of cardiac arrhythmias was related to medical history of cardiovascular disease, but not to organic cerebral disorders. The ictal increase of heart rate was significantly higher and more abrupt in epileptic seizures than in psychogenic attacks. The ictal electroencephalogram/electrocardiogram may thus be applicable to the differential diagnosis between the epileptic and psychogenic seizures.

[18F]FDG-PET reveals temporal hypometabolism in patients with temporal lobe epilepsy even when quantitative MRI and histopathological analysis show only mild hippocampal damage.

BACKGROUND: The relationship between reduced glucose metabolism in positron emission tomography with fludeoxyglucose F 18 ([(18)F]FDG-PET) and hippocampal damage (HD) in patients with temporal lobe epilepsy is still unclear. OBJECTIVE: To determine whether the presence and severity of HD verified by quantitative magnetic resonance imaging (QMRI) and histopathological analysis affect the degree of hypometabolism. PATIENTS AND METHODS: Sixteen patients with drug-resistant temporal lobe epilepsy underwent [(18)F]FDG-PET and QMRI (hippocampal volumetry and T2 relaxometry) before surgery. Histopathological analysis of the hippocampus included measurements of neuronal loss, proliferation of glial cells, and mossy fiber sprouting. The asymmetry in glucose metabolism described the degree of hypometabolism. RESULTS: Temporal hypometabolism was not related to severity of HD as measured by QMRI or histopathological analysis. The degree of hypometabolism did not differ in patients with mild, moderate, or severe HD. In addition, [(18)F]FDG-PET revealed significant temporal hypometabolism even though hippocampal QMRI findings were normal or showed only mild HD. Thus, glucose consumption was reduced over and above the histopathological changes. CONCLUSIONS: [(18)F]FDG-PET is sensitive for localizing the epileptogenic region in patients with temporal lobe epilepsy. However, it is insensitive to reflect the severity of HD.

Long-term antiepileptic efficacy of vigabatrin in drug-refractory epilepsy in mentally retarded patients. A 5-year follow-up study.

The long-term clinical, neurophysiologic, and psychological effects of add-on vigabatrin treatment were evaluated in a group of 36 mentally handicapped patients with drug-refractory epilepsy. After an initial 3-month follow-up period, 15 (42%) of 36 patients had at least a 50% decrease in seizure frequency compared with baseline. After a 2-year follow-up period, nine (25%) of 36 patients retained the initially observed antiepileptic effects of vigabatrin, and after 5 years, eight (22%) of 36 patients did so. Five (33%) of the 15 patients who initially exhibited a favorable antiepileptic response to vigabatrin lost that response during a 5-year follow-up. Partial-onset seizures represented the seizure type best controlled by vigabatrin. Side effects were mostly mild, and plasma levels of other antiepileptic medication remained unchanged. No impairment of psychological performance was observed during vigabatrin treatment compared with baseline. Also, no clear change was observed in the background or epileptiform activity in the electroencephalogram during the study. Our findings suggest that vigabatrin as an add-on therapeutic effectively controls seizures in a subpopulation of patients with severe epilepsy. In addition, the antiepileptic response, if achieved, is long lasting in about half of the patients.

Vigabatrin in drug-resistant partial epilepsy: a 5-year follow-up study.

We treated 75 patients with drug-resistant complex partial seizures and secondarily generalized seizures with vigabatrin as additional therapy for 6 months. Twenty-one patients either showed no benefit from vigabatrin treatment or had side effects. The remaining 54 patients entered into the long-term study. The median monthly seizure frequency decreased from 12.5 at baseline to 3.3 at the 3-month visit, and was 3.9 after 5 years of therapy in 28 patients who continued using the drug after the 5-year period. During 5 years of therapy with vigabatrin, 26 patients have withdrawn from the study because of various reasons: loss of efficacy (14), suspected side effects (5), noncompliance (3), administrative reasons (2), pregnancy (1), and epilepsy surgery (1). In all, 19 patients had a greater than 50% seizure frequency reduction at 5 years, representing 35% of the 54 patients who entered the long-term study, or 25% of the 75 patients who were initially recruited into the efficacy study.

[11 C]Flumazenil binding in the medial temporal lobe in patients with temporal lobe epilepsy: correlation with hippocampal MR volumetry, T2 relaxometry, and neuropathology.

OBJECTIVE: To detect reduced [11C]flumazenil in patients with temporal lobe epilepsy (TLE) and to relate binding to histopathology. METHODS: The authors studied 16 patients who underwent epilepsy surgery because of drug-resistant TLE using [11C]flumazenil PET and quantitative MRI. In 12 patients, resected hippocampus was available for histologic analysis. [11C]Flumazenil binding potential (fitted BP) was assessed with the simplified reference tissue model. RESULTS: [11C]Flumazenil fitted BP in the medial temporal lobe was reduced in all patients with abnormal hippocampal volumetry or T2 relaxometry on MRI. Fitted BP was also reduced in 46% of the patients with hippocampal volume within the normal range and in 38% of patients with less than 2 SD T2 prolongation. In all MRI-negative/PET-positive patients, the histologic analysis verified hippocampal damage. Also, [11C]flumazenil fitted BP correlated with the severity of reduced hippocampal volume, T2 prolongation, and histologically assessed neuronal loss and astrogliosis. CONCLUSION: [11C]Flumazenil PET provides a useful tool for investigating the hippocampal damage in vivo even in patients with no remarkable hippocampal abnormalities on quantitative MRI.

Reciprocal connections between the amygdala and the hippocampal formation, perirhinal cortex, and postrhinal cortex in rat. A review.

Recent anterograde and retrograde studies in the rat have provided detailed information on the origin and termination of the interconnections between the amygdaloid complex and the hippocampal formation and parahippocampal areas (including areas 35 and 36 of the perirhinal cortex and the postrhinal cortex). The most substantial inputs to the amygdala originate in the rostral half of the entorhinal cortex, the temporal end of the CA1 subfield and subiculum, and areas 35 and 36 of the perirhinal cortex. The amygdaloid nuclei receiving the heaviest inputs are the lateral, basal, accessory basal, and central nuclei as well as the amygdalohippocampal area. The heaviest projections from the amygdala to the hippocampal formation and the parahippocampal areas originate in the lateral, basal, accessory basal, and posterior cortical nuclei. These pathways terminate in the rostral half of the entorhinal cortex, the temporal end of the CA3 and CA1 subfields or the subiculum, the parasubiculum, areas 35 and 36 of the perirhinal cortex, and the postrhinal cortex. The connectional data are summarized and the underlying principles of organization of these projections are discussed.

NMDA-sensitive [3H]glutamate binding in the epileptic rat hippocampus: an autoradiographic study.

Sustained stimulation of the perforant pathway (PP) offers a model for studying seizure-induced pathology of the hippocampal formation. Using quantitative autoradiography, NMDA-sensitive glutamate binding was evaluated in the rat hippocampus three weeks after PP-stimulation. Decreased receptor binding (38-44%) was found together with pyramidal cell damage and gliosis in the CA1 area, ipsilateral to the stimulation (p < or = 0.001). In the dentate gyrus, however, a 20% increase in receptor density was observed bilaterally within the molecular layer (significant within the outer molecular layer of the contralateral side, on the suprapyramidal location; p < or = 0.05). These results are similar to those found in epileptic patients and suggest a prominent role for NMDA receptors in epilepsy.

Somatostatin, beta-endorphin, and prolactin levels in human cerebrospinal fluid during the gamma-vinyl-GABA treatment of patients with complex partial epilepsy.

The anticonvulsant action of the new anticonvulsant drug gamma-vinyl-GABA (GVG) is obviously mediated by elevation of the concentration of GABA in the brain. The effect of GVG administration on other transmitter systems is not fully known in humans. We studied the possible interactions of GVG administration with peptidergic systems. Included in this study were 67 patients with complex partial epilepsy (CPS). The first CSF sample was taken before GVG administration. The second CSF sample was taken after 3 months of GVG treatment (3 g/day). Thereafter half of the responders (50% decrease in seizure frequency or clear improvement in global performance) received 3 g/day and the other half received 1.5 g/day for the next three months, after which the third CSF sample was taken. Somatostatin (SLI), beta-endorphin (beta-EP), and prolactin (PROL) levels in CSF were measured by radioimmunoassay. Total GABA (tGABA) and GVG levels in CSF were measured by high performance liquid chromatography. After 3 months of GVG treatment there was a slight increase in the beta-EP (p = 0.027, Student's paired t-test), which was not found after 6 months of GVG administration. Both SLI and PROL were stable during the study. Peptide levels were not connected to the clinical response to GVG, GVG dosage, or to tGABA levels in the CSF. In conclusion, the elevation of GABA levels in the brain during GVG treatment apparently does not induce long-term interactions with the peptidergic systems studied.

Somatostatin and beta-endorphin levels in cerebrospinal fluid of nonmedicated and medicated patients with epileptic seizures.

Neuropeptides have been proposed to play a role in regulation of the seizure threshold and interictal behavior in experimental models of epilepsy, but there are few studies concerning neuropeptides in human epilepsy. We compared the levels of two peptides, somatostatin (SLI) and beta-endorphin (BEP) in lumbar cerebrospinal fluid (CSF) of unmedicated (N = 18) and medicated (n = 24) epileptic patients with the levels of these peptides in control (n = 20). Peptide levels in the CSF of patients with panic disorder (8) were also evaluated. Patients with chronic medicated epilepsy had a SLl level 80% (p = 0.003, Mann-Whitney U-test) that of the controls, 76% (p = 0.011) that of unmedicated patients, and 84% (p = 0.028) that of the panic group. BEP in the CSF did not differ in unmedicated, medicated and control patients. On the other hand, patients with panic disorder had higher levels of BEP in CSF than did the controls (117%, p = 0.041). In panic patients SLl was at control level. The present study indicates that the peptidergic systems are affected differentially in epilepsy and in panic disorder. Furthermore, there seems to be selectivity in the affect on peptidergic systems during the period when the epilepsy becomes chronic.