RESUMO
PURPOSE: The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out. METHODS: A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey. RESULTS: The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement. CONCLUSION: Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/métodos , Pneumonia Viral/epidemiologia , Antropologia Médica , Betacoronavirus , COVID-19 , Consenso , Atenção à Saúde/métodos , Desinfecção/métodos , Desinfecção/normas , Europa (Continente) , Unidades Hospitalares/organização & administração , Unidades Hospitalares/normas , Humanos , Salas Cirúrgicas/organização & administração , Salas Cirúrgicas/normas , Procedimentos Ortopédicos , Ortopedia , Pandemias , Equipamento de Proteção Individual , SARS-CoV-2 , Inquéritos e QuestionáriosRESUMO
PURPOSE: The COVID-19 pandemic has disrupted the health care system around the entire globe. A consensus is needed about resuming total hip and knee procedures. The European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus statement on how the safe re-introduction of elective hip and knee arthroplasty should be undertaken. METHODS: A prospective online survey was done among members of EHS and EKA. The survey consisted of 27 questions. It includes basic information on demographics and details the participant's agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). Recommendations focussed on pre-operative, peri-operative, and post-operative handling of patients and precautions. RESULTS: A total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The participants were from 44 countries and 6 continents. Apart from adhering to National and Local Guidelines, the recommendations concerned how to make elective arthroplasty safe for patients and staff. CONCLUSION: The survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the first wave of the COVID-19 pandemic.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Infecções por Coronavirus/epidemiologia , Atenção à Saúde/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Betacoronavirus , COVID-19 , Consenso , Europa (Continente) , Humanos , Cirurgiões Ortopédicos , Pandemias , Estudos Prospectivos , SARS-CoV-2 , Inquéritos e QuestionáriosRESUMO
18F-fluoroethoxybenzovesamicol (FEOBV) is a new PET radiotracer that binds to the vesicular acetylcholine transporter. In both animals and healthy humans, FEOBV was found sensitive and reliable to characterize presynaptic cholinergic nerve terminals in the brain. It has been used here for we believe the first time in patients with Alzheimer's disease (AD) to quantify brain cholinergic losses. The sample included 12 participants evenly divided in healthy subjects and patients with AD, all assessed with the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) cognitive scales. Every participant underwent three consecutive PET imaging sessions with (1) the FEOBV as a tracer of the cholinergic terminals, (2) the 18F-NAV4694 (NAV) as an amyloid-beta tracer, and (3) the 18F-Fluorodeoxyglucose (FDG) as a brain metabolism agent. Standardized uptake value ratios (SUVRs) were computed for each tracer, and compared between the two groups using voxel wise t-tests. Correlations were also computed between each tracer and the cognitive scales, as well as between FEOBV and the two other radiotracers. Results showed major reductions of FEOBV uptake in multiple cortical areas that were evident in each AD subject, and in the AD group as a whole when compared to the control group. FDG and NAV were also able to distinguish the two groups, but with lower sensitivity than FEOBV. FEOBV uptake values were positively correlated with FDG in numerous cortical areas, and negatively correlated with NAV in some restricted areas. The MMSE and MoCA cognitive scales were found to correlate significantly with FEOBV and with FDG, but not with NAV. We concluded that PET imaging with FEOBV is more sensitive than either FDG or NAV to distinguish AD patients from control subjects, and may be useful to quantify disease severity. FEOBV can be used to assess cholinergic degeneration in human, and may represent an excellent biomarker for AD.
Assuntos
Doença de Alzheimer/diagnóstico por imagem , Piperidinas/metabolismo , Tomografia por Emissão de Pósitrons/métodos , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/metabolismo , Peptídeos beta-Amiloides/metabolismo , Encéfalo/diagnóstico por imagem , Encéfalo/fisiologia , Estudos de Casos e Controles , Colinérgicos , Neurônios Colinérgicos/metabolismo , Neurônios Colinérgicos/fisiologia , Feminino , Fluordesoxiglucose F18/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Terminações Pré-Sinápticas/metabolismo , Traçadores Radioativos , Proteínas Vesiculares de Transporte de AcetilcolinaRESUMO
We report the case of a 53-year-old female, treated by bisphosphonate for 12 years, who presented atraumatic fractures of both fibulas. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. The distal fibula should be considered as a potential site for stress fractures in bisphosphonate users. Bisphosphonates are the most widely used drugs in the treatment of osteoporosis. During the last decade, the occurrence of atypical fractures, mostly subtrochanteric and diaphyseal femoral fractures, has been acknowledged in patients with long-term use of bisphosphonates. We report the case of a 53-year-old female on alendronate therapy for the past 12 years who presented with a few months history of atraumatic right, and subsequently left, lateral ankle pain. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. She had been treated conservatively with walking boots and her treatment with bisphosphonate had been stopped 5 months prior to the fractures. Callus was progressively seen on serial follow-up X-rays, and both fractures healed completely within a reasonable period of 1 year. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders. To our knowledge, this is the first reported case of bilateral distal fibula fractures in a patient on long-term bisphosphonate therapy.
Assuntos
Conservadores da Densidade Óssea/efeitos adversos , Difosfonatos/efeitos adversos , Fíbula/lesões , Fraturas de Estresse/induzido quimicamente , Alendronato/efeitos adversos , Alendronato/uso terapêutico , Traumatismos do Tornozelo/induzido quimicamente , Traumatismos do Tornozelo/diagnóstico por imagem , Conservadores da Densidade Óssea/uso terapêutico , Difosfonatos/uso terapêutico , Feminino , Fíbula/diagnóstico por imagem , Fraturas de Estresse/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Osteoporose Pós-Menopausa/tratamento farmacológico , RadiografiaRESUMO
OBJECTIVES: Psychotic symptoms associated with Alzheimer Disease (AD) contribute to excess functional dependence. Longitudinal studies have generally examined the association between rates of functional decline and the occurrence of psychotic symptoms from either a single evaluation or from multiple evaluations rather than through changes in frequency and severity of symptoms. Although the presence or absence of psychotic symptoms at initial or follow-up examinations may be associated with changes in functional status, the nature of the relationship between changes in these domains cannot be inferred. We examine the association between changes in the frequency of psychotic symptoms and changes in dependence in activities of daily living (ADL) over a period ranging from 1 to 74 months (median = 17.7). METHOD: Data from a cohort of 234 individuals referred to a memory clinic were analyzed using multilevel linear regression. Information on ADL, behavioral and psychological symptoms, depression, and cognition was collected. RESULTS: An increase in the frequency of psychotic symptoms had a unique influence on the deterioration of basic ADL, after controlling for demographic variables, changes in cognition, depression, and other behavioral and psychological symptoms (B = -.017, p = .003). However, changes in psychotic symptoms did not significantly contribute to declines in the ability to perform instrumental ADL (B = -.008, p = .439). CONCLUSION: Changes in psychotic symptoms may influence basic but not instrumental ADL over time. These findings may have ramifications for studies and treatment plans for individuals with AD who demonstrate psychotic symptoms.
Assuntos
Atividades Cotidianas/psicologia , Doença de Alzheimer/psicologia , Depressão/etiologia , Transtornos Psicóticos/etiologia , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/fisiopatologia , Estudos de Coortes , Análise Fatorial , Feminino , Humanos , Modelos Lineares , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Escalas de Graduação PsiquiátricaRESUMO
The primary objective of this study was to evaluate the effects of a 3-week treatment with tiotropium on walking capacity in chronic obstructive pulmonary disease (COPD). After familiarisation with study procedures, 36 patients were randomised to receive tiotropium 18 µg once daily or a matching placebo in a double-blind, parallel-group study. Pre- (trough) and 2-h post-dose pulmonary function was measured. An endurance shuttle walk was then completed. The same procedures were repeated after 3 weeks of treatment. Ventilatory parameters were monitored during exercise. At 3 weeks, tiotropium significantly improved walking endurance time in comparison with placebo, with a mean±sd between-group difference of 128±141 s (p=0.017). At 3 weeks, trough values for forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were significantly improved with tiotropium in comparison with placebo. The post-dose response to tiotropium was statistically superior to placebo after the first dose and after 3 weeks of treatment for FEV(1), FVC and inspiratory capacity. Ventilation and tidal volume at the end of walking were significantly improved with tiotropium. 3 weeks of tiotropium resulted in a greater walking endurance in patients with COPD. Improvements in FEV(1), maximal ventilation and tidal volume may contribute to this enhanced exercise capacity.
Assuntos
Broncodilatadores/administração & dosagem , Resistência Física/efeitos dos fármacos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Derivados da Escopolamina/administração & dosagem , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes de Função Respiratória , Brometo de Tiotrópio , Resultado do Tratamento , CaminhadaRESUMO
The medial temporal lobe (MTL) is a nidus for neurodegenerative pathologies and therefore an important region in which to study polypathology. We investigated associations between neurodegenerative pathologies and the thickness of different MTL subregions measured using high-resolution post-mortem MRI. Tau, TAR DNA-binding protein 43 (TDP-43), amyloid-ß and α-synuclein pathology were rated on a scale of 0 (absent)-3 (severe) in the hippocampus and entorhinal cortex (ERC) of 58 individuals with and without neurodegenerative diseases (median age 75.0 years, 60.3% male). Thickness measurements in ERC, Brodmann Area (BA) 35 and 36, parahippocampal cortex, subiculum, cornu ammonis (CA)1 and the stratum radiatum lacunosum moleculare (SRLM) were derived from 0.2 × 0.2 × 0.2 mm3 post-mortem MRI scans of excised MTL specimens from the contralateral hemisphere using a semi-automated approach. Spearman's rank correlations were performed between neurodegenerative pathologies and thickness, correcting for age, sex and hemisphere, including all four proteinopathies in the model. We found significant associations of (1) TDP-43 with thickness in all subregions (r = - 0.27 to r = - 0.46), and (2) tau with BA35 (r = - 0.31) and SRLM thickness (r = - 0.33). In amyloid-ß and TDP-43 negative cases, we found strong significant associations of tau with ERC (r = - 0.40), BA35 (r = - 0.55), subiculum (r = - 0.42) and CA1 thickness (r = - 0.47). This unique dataset shows widespread MTL atrophy in relation to TDP-43 pathology and atrophy in regions affected early in Braak stageing and tau pathology. Moreover, the strong association of tau with thickness in early Braak regions in the absence of amyloid-ß suggests a role of Primary Age-Related Tauopathy in neurodegeneration.
Assuntos
Córtex Entorrinal/diagnóstico por imagem , Hipocampo/diagnóstico por imagem , Doenças Neurodegenerativas/diagnóstico por imagem , Lobo Temporal/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/diagnóstico por imagem , Doença de Alzheimer/metabolismo , Doença de Alzheimer/patologia , Peptídeos beta-Amiloides/metabolismo , Espessura Cortical do Cérebro , Região CA1 Hipocampal/diagnóstico por imagem , Região CA1 Hipocampal/metabolismo , Região CA1 Hipocampal/patologia , Estudos de Casos e Controles , Proteínas de Ligação a DNA/metabolismo , Córtex Entorrinal/metabolismo , Córtex Entorrinal/patologia , Feminino , Degeneração Lobar Frontotemporal/diagnóstico por imagem , Degeneração Lobar Frontotemporal/metabolismo , Degeneração Lobar Frontotemporal/patologia , Hipocampo/metabolismo , Hipocampo/patologia , Humanos , Doença por Corpos de Lewy/diagnóstico por imagem , Doença por Corpos de Lewy/metabolismo , Doença por Corpos de Lewy/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Doenças Neurodegenerativas/metabolismo , Doenças Neurodegenerativas/patologia , Emaranhados Neurofibrilares/patologia , Giro Para-Hipocampal/diagnóstico por imagem , Giro Para-Hipocampal/metabolismo , Giro Para-Hipocampal/patologia , Doença de Pick/diagnóstico por imagem , Doença de Pick/metabolismo , Doença de Pick/patologia , Placa Amiloide/patologia , Paralisia Supranuclear Progressiva/diagnóstico por imagem , Paralisia Supranuclear Progressiva/metabolismo , Paralisia Supranuclear Progressiva/patologia , Lobo Temporal/metabolismo , Lobo Temporal/patologia , alfa-Sinucleína/metabolismo , Proteínas tau/metabolismoRESUMO
Objective: This study aimed to reproduce the results of a previous investigation on the safety benefits of individualized training for older drivers. We modified our method to address validity and generalizability issues. Methods: Older drivers were randomly assigned to one of the 3 arms: (1) education alone, (2) education + on road training, and (3) education + on road + simulator training. Older drivers were recruited from a larger urban community. At the pre- and posttests (separated by 4 to 8 weeks) participants followed driving directions using a Global Positioning System (GPS) navigation system. Results: Our findings support the positive influence of individualized on-road training for urban-dwelling older drivers. Overall, driving safety improved among drivers who received on-road training over those who were only exposed to an education session, F(1, 40) = 11.66, P = .001 (26% reduction in total unsafe driving actions [UDAs]). Statistically significant improvements were observed on observation UDAs (e.g., scanning at intersections, etc.), compliance UDAs (e.g., incomplete stop), and procedural UDAs (e.g., position in lane). Conclusion: This study adds to the growing evidence base in support of individualized older driver training to optimize older drivers' safety and promote continued safe driving.
Assuntos
Condução de Veículo/educação , Condução de Veículo/estatística & dados numéricos , Segurança/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Canadá , Feminino , Seguimentos , Sistemas de Informação Geográfica , Humanos , Masculino , Avaliação de Programas e Projetos de Saúde , População Urbana/estatística & dados numéricosRESUMO
Sensorimotor adaptation is thought to involve a remapping of the kinematic and kinetic parameters associated with movements performed within a changing environment. Patients with Parkinson's disease (PD) are known to be affected on this type of learning process, although the specific role of dopamine depletion in these deficits has not yet been elucidated. The present study was an attempt to clarify whether dopamine depletion in PD may directly affect the capacity to internally reorganize the visuomotor remapping of a distorted environment. Fourteen PD patients were tested twice, while they were treated and while they were withdrawn from their regular levodopa treatment. Fourteen control subjects were also enrolled and tested twice. Two parallel forms of the Computed Mirror Pointing Task (CMPT), requiring making a reaching movement in a visually transformed environment (mirror inversion), were administered to each participant. Each of them had to perform 40 trials at each of the 2 testing sessions. At each trial, sensorimotor adaptation was evaluated by the initial direction angle (IDA), which reflects the direction of movement before any visually guided readjustment. Results revealed no IDA difference at baseline, between control subject and PD patients, whether they were treated or not. In all group, IDA values at that time were large, reflecting a tendency to make movements according to the real life visuomotor mapping (based on the natural direct vision). However, striking differences appeared during sensorimotor learning, in that IDA reduction along trials was poorer in patient not treated with levodopa than both control subjects and the same PD patient treated with levodopa. No difference was observed between the treated PD patients and control subjects. Given that IDA is thought to reflect the internal representation of the visuomotor mapping, it is concluded that dopamine depletion in PD would affects sensorimotor adaptation, in that it facilitates old and poorly adapted movements (real life mapping), instead of new and more adapted ones (mirror transformed mapping).
Assuntos
Adaptação Fisiológica/fisiologia , Dopamina/metabolismo , Levodopa/uso terapêutico , Doença de Parkinson/metabolismo , Doença de Parkinson/fisiopatologia , Desempenho Psicomotor/fisiologia , Adaptação Fisiológica/efeitos dos fármacos , Idoso , Dopamina/deficiência , Feminino , Humanos , Levodopa/farmacologia , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/tratamento farmacológico , Estimulação Luminosa/métodos , Desempenho Psicomotor/efeitos dos fármacosRESUMO
Results obtained in patients with schizophrenia have shown that antipsychotic drugs may induce motor learning deficits correlated with the striatal type-2 dopamine receptors (D(2)R) occupancy. Other findings suggest that the role of the striatum in motor learning could be related to a process of "chunking" discrete movements into motor sequences. We therefore hypothesized that a D(2)R blocking substance, such as raclopride, would affect motor learning by specifically disrupting the grouping of movements into sequences. Two monkeys were first trained to perform a baseline-overlearned sequence (Seq. A) drug free. Then, a new sequence was learned (Seq. B) and the overlearned sequence was recalled OFF-drug (Seq. A recall OFF-drug). The effect of raclopride was then assessed on the learning of a third sequence (Seq. C), and on the recall of the overlearned sequence (Seq. A recall ON-drug). Results showed that performance related to the overlearned sequence remained the same in the three experimental conditions (Seq. A, Seq. A recall OFF-drug, Seq. A recall ON-drug), whether the primates received raclopride or not. On the other hand, new sequence learning was significantly affected during raclopride treatment (Seq. C), when compared with new sequence learning without the effect of any drug (Seq. B). Raclopride-induced disturbances consisted in performance fluctuations, which persisted even after many days of trials, and prevented the monkeys from reaching a stable level of performance. Further analyses also showed that these fluctuations appeared to be related to monkeys' inability to group movements into single flowing motor sequences. The results of our study suggest that dopamine is involved in the stabilization or consolidation of motor performances, and that this function would involve a chunking of movements into well-integrated sequences.
Assuntos
Antagonistas de Dopamina/efeitos adversos , Transtornos da Memória/induzido quimicamente , Movimento/efeitos dos fármacos , Racloprida/efeitos adversos , Receptores de Dopamina D2/fisiologia , Aprendizagem Seriada/efeitos dos fármacos , Animais , Comportamento Animal/efeitos dos fármacos , Cebus , Rememoração Mental/efeitos dos fármacos , Desempenho Psicomotor/efeitos dos fármacosRESUMO
Congenital hepatic arteriovenous malformations are rare anomalies, which typically present in infancy with congestive heart failure, anemia, and hepatomegaly. Morbidity and mortality is high if the condition is not recognized and treated promptly. Hepatic arteriovenous malformation associated with persistent pulmonary hypertension of the newborn has been reported in two cases in the literature. We report a neonate who was referred for management of persistent pulmonary hypertension and was subsequently diagnosed with a large hepatic arteriovenous malformation. He underwent coil embolization following which pulmonary hypertension resolved.
Assuntos
Malformações Arteriovenosas/diagnóstico , Artéria Hepática/anormalidades , Veias Hepáticas/anormalidades , Síndrome da Persistência do Padrão de Circulação Fetal/etiologia , Malformações Arteriovenosas/complicações , Malformações Arteriovenosas/terapia , Embolização Terapêutica , Humanos , Recém-Nascido , MasculinoRESUMO
BACKGROUND: Medical illnesses are associated with a modest increase in crash risk, although many individuals with acute or chronic conditions may remain safe to drive, or pose only temporary risks. Despite the extensive use of national guidelines about driving with medical illness, the quality of these guidelines has not been formally appraised. AIM: To systematically evaluate the quality of selected national guidelines about driving with medical illness. DESIGN: A literature search of bibliographic databases and Internet resources was conducted to identify the guidelines, each of which was formally appraised. METHODS: Eighteen physicians or researchers from Canada, Australia, Ireland, USA and UK appraised nine national guidelines, applying the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS: Relative strengths were found in AGREE II scores for the domains of scope and purpose, stakeholder involvement and clarity of presentation. However, all guidelines were given low ratings on rigour of development, applicability and documentation of editorial independence. Overall quality ratings ranged from 2.25 to 5.00 out of 7.00, with modifications recommended for 7 of the guidelines. Intra-class coefficients demonstrated fair to excellent appraiser agreement (0.57-0.79). CONCLUSIONS: This study represents the first systematic evaluation of national-level guidelines for determining medical fitness to drive. There is substantive variability in the quality of these guidelines, and rigour of development was a relative weakness. There is a need for rigorous, empirically derived guidance for physicians and licensing authorities when assessing driving in the medically ill.
Assuntos
Doença Aguda , Condução de Veículo , Doença Crônica , Guias de Prática Clínica como Assunto/normas , Medicina Baseada em Evidências , Humanos , Cooperação Internacional , Variações Dependentes do Observador , Medição de RiscoRESUMO
OBJECTIVE: To determine the frequency of REM sleep behavior disorder (RBD) among patients with PD using both history and polysomnography (PSG) recordings and to further study REM sleep muscle atonia in PD. BACKGROUND: The reported occurrence of RBD in PD varies from 15 to 47%. However, no study has estimated the frequency of RBD using PSG recordings or analyzed in detail the characteristics of REM sleep muscle atonia in a large group of unselected patients with PD. METHODS: Consecutive patients with PD (n = 33) and healthy control subjects (n = 16) were studied. Each subject underwent a structured clinical interview and PSG recording. REM sleep was scored using a method that allows the scoring of REM sleep without atonia. RESULTS: One third of patients with PD met the diagnostic criteria of RBD based on PSG recordings. Only one half of these cases would have been detected by history. Nineteen (58%) of 33 patients with PD but only 1 of 16 control subjects had REM sleep without atonia. Of these 19 patients with PD, 8 (42%) did not present with behavioral manifestations of RBD, and their cases may represent preclinical forms of RBD associated with PD. Moreover, the percentage of time spent with muscle atonia during REM sleep was lower among patients with PD than among healthy control subjects (60.1% vs 93.2%; p = 0.003). CONCLUSIONS: RBD and REM sleep without atonia are frequent in PD as shown by PSG recordings.
Assuntos
Hipertonia Muscular/complicações , Hipertonia Muscular/diagnóstico , Doença de Parkinson/complicações , Transtorno do Comportamento do Sono REM/complicações , Transtorno do Comportamento do Sono REM/diagnóstico , Idoso , Eletroencefalografia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Tono Muscular , Doença de Parkinson/diagnóstico , Doença de Parkinson/fisiopatologia , Polissonografia , Valor Preditivo dos Testes , Transtorno do Comportamento do Sono REM/fisiopatologiaRESUMO
Sleep architecture and quantitative EEG from wakefulness and REM sleep were studied in six patients (mean age, 70.5 years) with progressive supranuclear palsy (PSP) and compared with that of six control subjects (mean age, 69.8 years). Particular attention was given to quantifying REM sleep variables because of the known PSP-associated degeneration of the pedunculopontine tegmentum (PPT)--a critical structure in REM sleep generation. Patients with PSP had a shorter total sleep time, a lower sleep efficiency, a drastic reduction in sleep spindles, an atonic slow-wave sleep, and a lower percentage of REM sleep. The lower percentage of REM sleep was the result of both a reduction in the number of REM periods and a reduction in mean period of duration. REM density was also reduced while REM efficiency, atonia, and phasic EMG were similar to control values. REM sleep findings are consistent with the known role of the PPT in REM sleep induction. A slowing of the awake EEG was found for the six frontal leads and for C4, P4, and T4 in PSP patients. The frontal EEG slowing found in wakefulness is in accord with imaging and neuropsychological studies showing impairment of the frontal lobes in these patients. REM sleep EEG was not significantly slower in any regions. Because all previous studies on PSP have relied on visual inspection of the EEG tracings, the present finding of EEG slowing in the frontal lobes (rather than in the temporal regions or diffusely) suggests that our quantitative EEG approach may be more useful in determining specific regions of impaired cortical activity.
Assuntos
Eletroencefalografia , Sono/fisiologia , Paralisia Supranuclear Progressiva/diagnóstico , Paralisia Supranuclear Progressiva/fisiopatologia , Idoso , Ritmo Circadiano , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Tempo de Reação , Fases do Sono , Paralisia Supranuclear Progressiva/psicologiaRESUMO
The paradigm of the covert orienting of attention (COA) has shown that the displacement of visual attention may be assessed even in the absence of eye movement. Stimuli correctly cued before their presentation are usually detected faster than uncued stimuli. However, miscued stimuli induce an increased detection time, which has been attributed to the time required for the reorientation of attention from the incorrect to the correct spatial location. Currently, the mechanism of such a displacement of visual attention remains unknown. Rizzolatti et al. Neuropsychologia 25, 31-40 (1987) have suggested a premotor hypothesis which suggests that an oculomotor disprogramming and reprogramming is necessary to reorient visual attention, even if the eye movement is inhibited. Since shifting of auditory attention from one ear to the other does not require any motor control, we further investigated the model of COA in 20 normal subjects who performed two tasks requiring a reorienting of auditory attention: (1) a choice RT task that requires a response readjustment during the auditory reorienting; (2) a simple RT task that does not require a response readjustment during the auditory reorienting; (2) a simple RT task that does not require a response readjustment during the auditory reorienting. Results indicate that correctly cued stimuli significantly reduce the RT in both tasks and that this reduction is greater in the choice than in the simple RT task. This suggests that a correct cue may produce a pre-programming of the response, in addition to the pre-engagement of the perceptual attention.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Atenção/fisiologia , Orientação/fisiologia , Estimulação Acústica , Adulto , Análise de Variância , Sinais (Psicologia) , Feminino , Humanos , Masculino , Desempenho Psicomotor/fisiologia , Tempo de Reação/fisiologiaRESUMO
OBJECTIVE: To determine the incidence and site of single photon emission computed tomography scan (SPECT) abnormalities in survivors of neonatal extracorporeal membrane oxygenation and to evaluate the efficacy of SPECT scan as a predictor of neurodevelopmental outcome in these infants. SETTING: Tertiary care neonatal intensive care unit in Detroit, MI. PATIENT POPULATION: Survivors of neonatal extracorporeal membrane oxygenation who had a SPECT scan of the brain performed after decannulation and before their discharge from the neonatal intensive care unit were included if they had at least 12 months of follow-up in our developmental assessment clinic. OUTCOME MEASURES: The neurological outcome was reported as normal, suspect, and abnormal on the basis of neurological examination and developmental milestones. The developmental outcome was assessed by Bayley mental development index or McCarthy general cognitive index scores. RESULTS: A total of 59 patients met study criteria. SPECT scan abnormalities were noted in 45 (76%) infants. Global hypoperfusion was the most frequent abnormality followed closely by bilateral focal perfusion defects. The distribution of perfusion abnormalities was not significantly different for right and left hemispheres. Among 14 infants with normal SPECT scans, 13 infants had normal neurological outcome and all had a normal developmental outcome. Of the 45 infants with an abnormal SPECT scan, 7 infants had an abnormal neurological outcomes and 4 infants had an abnormal developmental outcome. SPECT scan abnormalities had no significant correlation with neurodevelopmental outcome of these infants. CONCLUSION: Although a normal SPECT scan was more likely to predict a normal neurodevelopmental outcome, an abnormal SPECT scan did not predict an abnormal outcome in these infants.
Assuntos
Encéfalo/diagnóstico por imagem , Deficiências do Desenvolvimento/epidemiologia , Oxigenação por Membrana Extracorpórea , Tomografia Computadorizada de Emissão de Fóton Único , Pré-Escolar , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Terapia Intensiva Neonatal , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To evaluate the effect of antenatal phenobarbital (PB) therapy on neurodevelopmental outcome at 36 months. DESIGN: Prospective, randomized, controlled trial. SETTING: Single-institution study. SUBJECT AND INTERVENTIONS: Children born to women who participated in the study evaluating the effect of antenatal phenobarbital (PB) on neonatal intracranial hemorrhage were prospectively followed to 3 years of age. OUTCOME MEASURES: Physical growth, neurologic examinations, and developmental testing (McCarthy Scales of Children's Abilities). Comparisons between groups were made on all children and those born to multiple gestations. RESULTS: Forty-one children born to women who received 10 mg/kg PB before delivery and 55 children in the control group were evaluated. Three children, all in the control group, had growth parameters (height, weight, and head circumference) below the fifth percentile. The McCarthy General Cognitive Index (standard, 100 +/- 16) was 93 +/- 20 in the PB group and 85 +/- 18 in the control group. The subscores tended to be higher in the PB group than in the control group, with higher quantitative scores in the PB group (44 +/- 11 vs 39 +/- 8). Neurologic deficits were noted in 2 of 41 in the PB group and in 6 of 55 in the control group. CONCLUSIONS: Infants born to women who received antenatal PB therapy had similar neurodevelopmental outcomes as infants born to women who did not receive PB. No adverse effects of PB exposure were detected.
Assuntos
Anticonvulsivantes/uso terapêutico , Desenvolvimento Infantil/efeitos dos fármacos , Sistema Nervoso/efeitos dos fármacos , Fenobarbital/uso terapêutico , Efeitos Tardios da Exposição Pré-Natal , Anticonvulsivantes/administração & dosagem , Estatura , Peso Corporal , Hemorragia Cerebral/prevenção & controle , Pré-Escolar , Cognição/efeitos dos fármacos , Feminino , Seguimentos , Crescimento/efeitos dos fármacos , Humanos , Lactente , Recém-Nascido , Troca Materno-Fetal , Exame Neurológico , Fenobarbital/administração & dosagem , Gravidez , Gravidez Múltipla , Estudos ProspectivosRESUMO
Length of stay data collected for high-risk newborn infants admitted to a tertiary care children's hospital neonatal unit over a 6-year period were compared with mean and outlier lengths of stay published in the Federal Register as part of a proposed system for prospective payment of hospital cost by diagnosis-related groupings (DRGs). We found that the classification system for newborns markedly underestimated the number of days required for the treatment of these infants. The use of the geometric mean instead of the arithmetic mean as the measure of central tendency was a significant contributor to the discrepancy, especially in those subgroups with bimodal frequency distributions of lengths of stay. Another contributor to the discrepancy was the lack of inborn patients in the children's hospital cohort. The system of prospective payments, as outlined, does not take into account several factors that have a strong influence on length of stay such as birth weight (which requires more than three divisions to serve as an effective predictor), surgery, outborn status, and ventilation. Implementation of the system described in the Federal Register would severely discourage tertiary care referral hospitals from providing neonatal intensive care.
Assuntos
Custos e Análise de Custo , Grupos Diagnósticos Relacionados , Doenças do Recém-Nascido/terapia , Tempo de Internação , Sistema de Pagamento Prospectivo , Mecanismo de Reembolso , Peso ao Nascer , Hospitais Pediátricos , Humanos , Recém-Nascido , Michigan , Risco , Estatística como AssuntoRESUMO
Forty-two premature infants less than 24 hours of age, with normal admission echoencephalograms, were randomly assigned to control or phenobarbital treatment groups. Infants in the treated group received two loading doses of 10 mg/kg of phenobarbital 12 hours apart, followed by a maintenance dose of 2.5 mg/kg every 12 hours for 6 days. Serial echoencephalograms were obtained in both groups. The groups were comparable with regard to birth weight, gestational age, and potential risk factors for subependymal-intraventricular hemorrhage. Ten infants (48%) in each group developed hemorrhage. The hemorrhages in the phenobarbital-treated group were significantly less severe than those in the control group. The phenobarbital-treated infants who bled, however, were also significantly larger and more mature than control infants who bled. The results of this study indicate no effect of phenobarbital on the incidence of subependymal-intraventricular hemorrhage, but a possible beneficial effect on the severity of hemorrhage.
Assuntos
Hemorragia Cerebral/prevenção & controle , Doenças do Prematuro/prevenção & controle , Fenobarbital/uso terapêutico , Hemorragia Cerebral/diagnóstico , Ensaios Clínicos como Assunto , Humanos , Recém-Nascido , Doenças do Prematuro/diagnóstico , Distribuição Aleatória , Risco , UltrassonografiaRESUMO
OBJECTIVE: To evaluate the effect of antenatal phenobarbital (PB) therapy on neonatal intracranial hemorrhage (ICH) in preterm infants. DESIGN: Prospective, randomized, controlled trial. SETTING: Single institution study. SUBJECTS AND INTERVENTIONS: Women in preterm labor ( < 35 weeks' gestation) were assigned to control and treatment groups. The treatment group received 10 mg/kg (maximum, 1000 mg) PB intravenously, followed by 100 mg orally daily, until delivery. Neonates did not receive PB after birth. Head sonograms were performed on days 3, 7, and 14 and at discharge. Hemorrhage was classified as mild, moderate, or severe by a single reader. OUTCOME MEASURES: Incidence of neonatal ICH in all infants, infants weighing less than 1250 g, and infants of multiple gestations. RESULTS: The study population comprised 110 women, 60 in the control group and 50 in the PB group. Neonates in the control group (n = 74, including 10 pairs of twins and 2 sets of triplets) were comparable to those in the treatment group (n = 62, including 7 pairs of twins, 1 set of triplets, and 1 set of quadruplets) regarding birth weight, gestational age, and other clinical risk factors for ICH. There was a trend for the incidence of any grade of hemorrhage to be lower in the PB group (22% [14 of 62]) compared with the control group (35% [26 of 74]). Moderate and severe hemorrhages were significantly lower in the PB group (1.6% [1 of 62]) compared with the control group (9.4% [7 of 74]). Among infants weighing less than 1250 g, overall ICH was lower in the PB group (23% [6 of 26]) compared with the control group (51% [18 of 35]). Among multiple-gestation infants, overall ICH was 4.7% (1 of 21) in the PB group, compared with 31% (8 of 26) in the control group. CONCLUSIONS: Antenatal PB therapy results in a significant decrease in moderate and severe ICH in infants born at less than 35 weeks' gestation. Antenatal PB therapy also resulted in a decrease in the incidence of all grades of ICH in infants weighing less than 1250 g and infants born of multiple gestations.