MRI verified STN stimulation site--gait improvement and clinical outcome.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in alleviating Parkinson's disease (PD) symptoms (tremor, rigidity and bradykinesia) and may improve gait and postural impairment associated with the disease. However, improvement of gait is not always as predictable as the clinical outcome. This may relate to the type of gait impairment or localization of the active DBS contact. METHODS: The active contact was visualized on peri-operative magnetic resonance imaging in 22 patients with idiopathic PD, consecutively treated with bilateral STN DBS. Stimulation site was grouped as either in the dorsal/ventral STN or medial/lateral hereof and anterior/posterior STN or medial/lateral hereof. The localization was compared with relative improvement of clinical outcome (UPDRS-III). In 10 patients, quantitative gait analyses were performed, and the improvement in gait performance was compared with stimulation site in the STN. RESULTS: Of 44 active contacts, 77% were inside the nucleus, 23% were medial hereof. Stimulation of the dorsal half improved UPDRS-III significantly more than ventral STN DBS (P = 0.02). However, there were no differences between anterior and posterior stimulation in the dorsal STN. Step velocity and length improved significantly more with dorsal stimulation compared with ventral stimulation (P = 0.03 and P = 0.02). Balance during gait was also more improved with dorsal stimulation compared with ventral stimulation. CONCLUSIONS: Deep brain stimulation of the dorsal STN is superior to stimulation of the ventral STN. Possible different effects of stimulation inside the nucleus underline the need for exact knowledge of the active stimulation site position to target the most effective area.

Power variations of wireless communication systems.

The use of wireless digital communication devices like GSM, WCDMA, HSPA, DECT, and WiFi changes the exposure of electromagnetic waves toward the user. Concentrating on the power variations on a slow and fast time scale, these new systems are discussed. Experimental results for both uplink and downlink are included for a sample of systems. The spectrum of the power fluctuations is seen as a convenient and compact way of describing very complex system behavior. The results are of interest for scientific studies of epidemiology and biological effects, and for general electromagnetic compatibility (EMC) aspects.

Neuromodulation in a minipig MPTP model of Parkinson disease.

Large animal neuroscience enables the use of conventional clinical brain imagers and the direct use and testing of surgical procedures and equipment from the human clinic. The greater complexity of the large animal brain additionally enables a more direct translation to human brain function in health and disease. Economical, ethical, scientific and practical issues may on the other hand hamper large animal neuroscience. Large animal neuroscience should therefore either be performed in order to examine large animal species dependent problems or to complement promising small animal basic studies by constituting an intermediate research system, bridging small animal CNS research to the human CNS. We have, accordingly, during the last ten years used the Gottingen minipig to examine neuromodulatory treatment modalities such as stem cell transplantation and deep brain stimulation directed towards Parkinson disease. This has been accomplished by the development of a MPTP-based large animal model of Parkinson disease in the Gottingen minipig and the development of stereotaxic and surgical approaches needed to manipulate the Gottingen minipig CNS. The instituted changes in the CNS can be evaluated in the live animal by brain imaging (PET and MR), cystometry, gait analysis, neurological evaluation and by post mortem examination based on histology and stereological analysis.

Effects of an outdoor bicycle-based intervention in healthy rural Indian men with normal and low birth weight.

Physical inactivity and low birth weight (LBW) may lead to an increased risk for developing type 2 diabetes. The extent to which LBW individuals may benefit from physical exercise training when compared with those with normal birth weight (NBW) controls is uncertain. We assessed the impact of an outdoor exercise intervention on body composition, insulin secretion and action in young men born with LBW and NBW in rural India. A total of 61 LBW and 56 NBW healthy young men were recruited into the study. The individuals were instructed to perform outdoor bicycle exercise training for 45 min every day. Fasting blood samples, intravenous glucose tolerance tests and bioimpedance body composition assessment were carried out. Physical activity was measured using combined accelerometry and heart rate monitoring during the first and the last week of the intervention. Following the exercise intervention, the LBW group displayed an increase in physical fitness [55.0 ml (O2)/kg min (52.0-58.0)-57.5 ml (O2)/kg min (54.4-60.5)] level and total fat-free mass [10.9% (8.0-13.4)-11.4% (8.0-14.6)], as well as a corresponding decline in the ratio of total fat mass/fat-free mass. In contrast, an increase in total fat percentage as well as total fat mass was observed in the NBW group. After intervention, fasting plasma insulin levels, homoeostasis model assessments (HOMA) of insulin resistance (HOMA-IR) and insulin secretion (HOMA-IS), improved to the same extent in both the groups. In summary, young men born with LBW in rural India benefit metabolically from exercise training to an extent comparable with NBW controls.

Selegiline and levodopa in early or moderately advanced Parkinson's disease: a double-blind controlled short- and long-term study.

Selegiline 10 mg per day was compared to placebo as an adjunct to levodopa treatment in this double-blind study of early or moderately advanced Parkinson's disease. Thirty-eight patients completed an initial cross-over trial comprising two treatment periods, each of eight weeks, with a four weeks' wash-out period between them. Thirty of the patients continued in a long-term, double-blind parallel trial with a mean duration of 16 months (range 6-30 months). Selegiline treatment allowed a significant reduction of the necessary daily levodopa dose in both parts of the study and of the daily dosing frequency in the long-term investigation. In spite of this reduction of levodopa dose, an improvement was noted in tremor during the short-term selegiline periods. The side-effects were slight and related to dopamine effects and disappeared after reduction of levodopa-dose. The results support the use of selegiline as an early adjunctive treatment in Parkinson's disease.

Cytotoxic activity in plasma from patients with amyotrophic lateral sclerosis.

The present study evaluates an assay of cytotoxic effect of plasma from patients with amyotrophic lateral sclerosis. Plasma from 20 recently diagnosed ALS patients induced hemolysis of normal red blood cells with a significantly greater intensity than that of normal controls. After at least 1 month of treatment with prednisone and azathioprine, the hemolytic activity of ALS plasma was reduced but was still higher than that of control plasma.

Initial sensorimotor and delayed autonomic neuropathy in acute thallium poisoning.

In a 27-year old male with acute thallium poisoning, signs of initially severe sensorimotor neuropathy with complete remission after two weeks were demonstrated. Signs of cardiovascular autonomic neuropathy were initially absent, but developed after a latency period of one week with marked improvement after seven months. Delayed autonomic neuropathy may be caused by a late affection of small unmyelinated autonomic nerve fibers.

[Extracorporeal shock wave treatment of urinary calculi. Results after treatment of the first 207 patients at the Copenhagen City Stone Center with a second generation lithotriptor]. / Ekstrakorporal trykbølgebehandling af urinvejskonkrementer. Resultater af behandling af de første 207 patienter ved Københavns Kommunes Stencenter med en 2. generations litotriptor.

Early experience of extracorporeal shock wave lithotripsy (ESWL) using a second generation lithotriptor (Siemens Lithostar) is reported. Two hundred and seven patients underwent 272 treatments for 291 stones. There were 259 renal calculi, including three staghorn calculi and 32 ureteric calculi. Treatments were performed under local analgesia (78%) or epidural or general anaesthesia (22%) when invasive procedures had to be done in connection with the treatment. Stone fragmentation was achieved with 2,487 +/- 1,262 shocks. The first month stone clearance rate was 43%, 24% had fragments less than 6 mm and 33% had residual stones. The same figures after three and six months were 57%, 23% and 20% and 71%, 23% and 6%, respectively. Septicaemia occurred in four patients and cardiac arrhythmia in 24 patients (12%); no serious intra- or perirenal heamatomas were registered. In 7% additional procedures were required, seven patients had residual stones removed at an open operation. The Lithostar is an effective second generation lithotriptor which can be used for renal, staghorn and ureteric calculi in situ in all three segments without stone manipulation prior to ESWL.

Extracorporeal shock wave lithotripsy of urinary calculi. Results from the first 306 patients treated at the Copenhagen Municipal Stone Center with a second generation lithotriptor.

The first Danish experience with Extracorporeal Shock Wave Lithotripsy (ESWL) using a second generation Lithotriptor (Siemens Lithostar) is reported. 306 patients underwent 392 treatments for 363 stones. There were 339 renal calculi including 5 staghorn calculi and 54 ureteral calculi. Treatments were performed under local analgesia (82%) or epidural or general anesthesia (18%) when invasive procedures had to be done in connection with the treatment. Stone fragmentation was achieved with 2487 +/- 1262 shocks. The first months stone clearance rate was 45%; 26% had fragments less than 6 mm; 29% had residual stones. Corresponding rates after 3 and 6 months were 58%, 24% and 18% and 70%, 21% and 9% respectively. Septicemia occurred in 4 patients and cardial arrhythmia in 34 patients (11%). No serious intra- or perirenal hematomas were registered. In 9% additional procedures were required and 11 patients had residual stones removed at open surgery. The used second generation lithotriptor with X-ray based stone localisation is effective for treatment of both renal calculi and ureteral calculi in situ in all three segments of the ureter.

Primary in situ extracorporeal shock wave lithotripsy for ureteral calculi.

The use of a second generation lithotriptor (Siemens Lithostar) for ESWL treatment of 199 consecutively referred patients with ureteral calculi is evaluated. Follow up data were available in all patients. In 79 patients the calculus was located in the upper third of the ureter, in 43 patients in the middle third and in 77 patients in the lower third of the ureter. In situ ESWL was performed in 187 patients (94%) under local infiltration analgesia, if invasive procedures in conjunction with ESWL were not planned. The overall stone free rates for all patients after 1, 3 and 6 months were 62.3%, 82.4% and 89.9% respectively. The size of the calculus influenced the outcome of treatment, the number of treatments and number of shock waves given. The stone free rates 3 and 6 months after ESWL in patients with upper ureteral calculi were 86.1% and 91.1%; the number of treatments per patient was 1.2. The corresponding rates for patients with mid or lower ureteral calculi were 76.7%, 86.0% (1.0 treatment) and 81.8%, 90.9% (1.2 treatment) respectively. ESWL alone failed to clear calculi in 4 patients with upper ureteral stones, 6 patients with mid-ureteral calculi and 14 patients with lower ureteral calculi. The number of additional procedures post-ESWL was significantly higher among patients with calculi in the lower third of the ureter. It is concluded, that ESWL in situ with a second generation lithotriptor using X-ray localization is an effective and noninvasive method to treat ureteral calculi. In situ ESWL is recommended as first line treatment for ureteral calculi in the upper and mid-thirds.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between urinary flow curve patterns and symptomatology in elderly males.

In a random sample of elderly males prostatic type flow curves constituted slightly more than 50%, but no differences were proven comparing persons with and without prostatism. Also no clinically significant relationships between symptoms of lower urinary tract dysfunction and the various flow curve patterns were established. A hypothesis is advanced concerning the sequence of flow curve changes in elderly males, from normal bell-shaped curves to prostatic and finally irregular types, reflecting prostatic hyperplasia with gradual detrusor decompensation.

Urodynamics in prostatism. I. Prognostic value of uroflowmetry.

A prospective study was undertaken to examine the prognostic value for the symptomatic outcome of prostatic surgery of preoperative urodynamic testing in patients with prostatism. The study design included selection of patients for prostatic surgery by means of classic non-urodynamic urologic investigations such as history, residual urine, serum creatinine, cystoscopy and possibly intravenous urography. In addition an extensive urodynamic work-up (uroflowmetry, cystometry and pressure-flow study with stop-test) was included. The results of the urodynamic studies were unknown to the surgeon selecting the patients for operation. This evaluation was repeated 6 months postoperatively. Totally 139 patients entered the study. The patients were classified according to the preoperative maximum flow rate (Qmax) and in spite of preoperative differences in uroflow, pressure-flow variables and symptom scores, no differences of clinical significance were noted postoperatively among the groups. However, the high-flow group (preoperative Qmax greater than or equal to 15 ml/sec) had a statistically significant lower success rate as judged by the patients subjective evaluation of the outcome of surgery. An analysis of diagnostic sensitivity and specificity indicated Qmax = 15 ml/sec as a relevant cut-off value regarding preoperative identification of patients at risk of a less favourable outcome of surgery. This group of patients was characterised by a higher incidence of persistent uninhibited detrusor contractions at follow-up and a lower incidence of preoperative infravesical obstruction. In conclusion we recommend uroflowmetry in the preoperative evaluation of patients with prostatism.

Urodynamics in prostatism. II. Prognostic value of pressure-flow study combined with stop-flow test.

In a prospective study the prognostic value of preoperative pressure-flow studies in prostatism was examined. The indications for prostatectomy were based on non-urodynamic data only. An extensive urodynamic evaluation was performed pre- and postoperatively, including uroflowmetry, water cystometry and pressure-flow study combined with stop-flow test. In total the data from 130 patients were considered. The material was classified with respect to the "urethral resistance relation" (URR) and the "bladder output relation" (BOR). According to the first criterion 87 patients were obstructed, 36 unobstructed, while 7 were unclassifiable and finally excluded. In most urodynamic variables, the two groups differed preoperatively, but no differences were revealed postoperatively. However, the obstructed group did considerably better postoperatively as to the symptomatic outcome. The success rate was 93% as opposed to 78% in the unobstructed patients (p less than 0.02). For the BOR classification, the theoretical maximum flow rate (Qm,est) was employed forming two groups: 57 patients with decreased bladder speed (Qm,est less than 35 ml/sec) and 41 patients with normal speed (Qm,est greater than or equal to 35 ml/sec). Few differences in urodynamic variables were found both pre- and postoperatively, but no significant difference was shown in success rates. In conclusion the URR proved a significant prognostic value in prostatism and is recommended in the preoperative work-up, especially in patients with equivocal uroflow studies. No convincing prognostic role could be attributed to the BOR.

Urodynamics in prostatism. III. Prognostic value of medium-fill water cystometry.

The influence of preoperative cystometric findings on the post-surgical outcome in prostatism was examined in a prospective study comprising 139 consecutive patients. A blinded study design was used, including an entirely non-urodynamic selection procedure for prostatic surgery. In addition an extensive urodynamic investigation was carried out including: spontaneous uroflowmetry, medium-fill water cystometry and pressure-flow study combined with stop-flow test. All patients were re-evaluated 6 months postoperatively, both symptomatologically and urodynamically. The patients were classified in three groups according to the preoperative detrusor function: normal, overactive in the standing position and overactive in the supine position. No significant urodynamic nor symptomatologic differences were shown, neither pre- nor postoperatively. Nor did the subjective outcome differ between the groups. Demonstration of postoperative (persistent) detrusor instability was associated with an unfavourable subjective outcome. While residual urine had no predictive importance, a preoperative maximum cystometric capacity less than 300 ml appeared to indicate postoperative failure. Significant association was found between urge and detrusor instability. In conclusion, cystometry is not worthwhile in the preoperative work-up in prostatism.

Urodynamics in prostatism. IV. Search for prognostic patterns as evaluated by linear discriminant analysis.

In order to examine the prognostic role of routine urodynamic testing in prostatism, a prospective study was undertaken. The patients were selected for prostatic surgery exclusively by means of non-urodynamic criteria, but in addition an extensive, blinded urodynamic work-up was performed, including uroflowmetry, pressure-flow study combined with stop-flow test and water cystometry. The study comprised 139 patients consecutively referred for prostatism. Six months postoperatively all patients were reexamined. Previously the preoperative urodynamic data from each modality were analysed separately. In an attempt to increase the prognostic information, all data were computed simultaneously using linear discriminant analysis. Several preoperative variables appeared valuable to discriminate between patients with favourable and unfavourable postoperative outcome, respectively. However, the results of classification employing even the best combinations of variables did not result in more than 88% of the patients being correctly classified. Furthermore, especially the patients with unfavourable outcome generally were misclassified. Several reasons for this lack of efficacy are briefly mentioned, including the great overlap in preoperative urodynamic data between patients with favourable and unfavourable postoperative outcome and the relatively low postoperative failure rate.